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Admission Date: [**2120-12-6**] Discharge Date: [**2120-12-19**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6565**]
Chief Complaint:
Right hip pain, unable to walk
Major Surgical or Invasive Procedure:
Partial Hip Replacement
History of Present Illness:
85 yo M with superficial bladder ca (dx [**2103**]) - stage IV, mets
to bone - R femur and s/p excision of R sided lung cancer [**2118**]
who presents with acute on chronic worsening of R hip pain felt
to be secondary to R femur metastatic lesion. He has actually
been unable to walk for the last 3 days and has been mostly
sitting in a chair at home. He had been evaluated for hospice
services, though recently doses not qualify as he is using
Aranesp (successfully) for anemia. He has tried Advil 600mg prn
leg pain as well as Tylenol #3 (taken infrequently) at home. He
is also using a Lidocaine patch. His pain in minimal while lying
in bed, though he likens standing and walking to "giving birth"
because the pain is so bad. He otherwise feels well. Nephrostomy
tubes are functioning well without bleeding. No SOB or chest
pain. No fevers.
Past Medical History:
ONCOLOGIC HISTORY: Mr. [**Known lastname 94340**] is an 84-year-old male with a
history of superficial bladder cancer originally diagnosed in
[**2103**] and treated with local resection and intravesicular BCG/IFN
in [**2114**] and [**2115**]. In [**2-/2118**], TURBT revealed papillary urothelial
carcinoma, largely low grade with focal high grade features and
lamina propria invasion in his prostatic urethra. He received
intravesicular BCG and IFN, completed in 3/[**2118**]. Restaging TURBT
on [**2118-6-17**] revealed two small recurrences of papillary
urothelial carcinoma, low-grade, with a
focus of invasion into the lamina propria but muscularis was
free
of tumor. Retrograde pyelograms demonstrated severe bilateral
hydronephrosis and he was in acute renal failure with Cr of 2.2,
up from 1.3. Ureteral obstruction was thought to be due to
locally advanced bladder cancer. Bilateral percutaneous
nephrostomy tubes were placed and he underwent 6660cGy of
radiation to the pelvis in [**10-14**]. The left nephrostomy tube was
removed on [**2119-1-3**]. The right nephrostomy tube was removed on
[**2119-2-16**] but on [**2119-4-4**], he developed bilateral hydronephrosis
again and a left nephrostomy tube was placed. He has had
multiple
complications, including ureteral obstruction, hydronephrosis,
renal failure (Cr of 2.8 in [**6-14**]) and hematuria felt to be due
to
radiation cystitis. Cystoscopy in [**1-14**] showed one tumor on the
right bladder wall which was fulgurated. Follow-up cystoscopy in
[**3-/2120**] was normal, but in [**2120-6-7**] he had several areas of
infiltrative papillary urothelial carcinoma. In [**2120-9-7**]
pelvic imaging disclosed stage IV bladder cancer and a
destructive bone lesion of the right lesser trochanter, for
which
he received radiation, completed on [**2120-10-9**].
.
PAST MEDICAL HISTORY:
# Superficial bladder cancer (see OMR for details)
# Squamous cell cancer RLL s/p excision [**11-13**]
# Adenocarcinoma in RML s/p excision [**11-13**]
# Lingular nodule, ? bronchoalveolar carcinoma
# CAD
# s/p pacemaker
# hypercholesterolemia
# s/p bilateral inguinal hernia repairs
# Chronic renal insufficiency, baseline Cr ~2.0 (stage III CKD)
Social History:
Lives with his wife. Difficult caring for him at home even prior
to this leg pain given severity of illnesses. Considering
hospice care.
Family History:
NC
Physical Exam:
Vitals: T 98.2 BP 168/64 HR 96 RR 18 O2 99% RA
GENERAL: WDWN older male in bed, awake and alert
HEENT: Sclerae anicteric. PERRL, EOMI. Conjunctiva injected and
pale, lower lids are lax
OP: MMM. Oropharynx is clear. No thrush. Neck supple.
LYMPH: No cervical, supraclavicular, infraclavicular or
axillary LAD.
HEART: Distant heart sounds, regular, with normal S1 and S2, no
murmurs.
LUNGS: Clear to auscultation and percussion bilaterally. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. + Quiet BS. No hepatosplenomegaly.,
pressure ulcers b/l ischial tub.
EXTREMITIES: 2+ pitting edema to his mid calves bilaterally.
Skin is flaky, warm
NEURO: Pain with abduction of R leg, no tenderness to palpation.
Unable to lift leg off bed due to pain.
Pertinent Results:
[**2120-12-6**] 02:50PM URINE BLOOD-LG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2120-12-6**] 02:50PM URINE RBC->50 WBC->50 BACTERIA-MOD YEAST-NONE
EPI-0
[**2120-12-6**] 12:00PM WBC-11.7* RBC-3.73* HGB-10.1* HCT-33.4*
MCV-90 MCH-27.1 MCHC-30.2* RDW-16.0*
.
XRay:
There is no evidence of a new fracture. Patient has known
osteolytic lesion in the proximal shaft of the femur and large
osteolytic lesion in the lesser trochanter; this is unchanged
from prior as does degenerative changes in the right hip joint.
.
CT Pelvis
1. Destructive mass involving the right lesser trochanter and
lateral subtrochanteric femur has progressed. There is high risk
for pathologic fracture if this has not already occurred.
Dedicated femur radiographs are recommended as this lesion is
only partially visualized.
2. New lesions within the left pubic symphysis and right sacrum.
The right sacral lesion abuts the S3 nerve root.
3. Slight progression of disease within the pelvis.
.
CT spine:
1. New right sacral lesion with soft tissue component, most
likely lytic
metastasis of rapid progression. These findings were not
appreciated on prior exam of [**2120-10-22**].
2. L3 left pedicle blastic lesion , overall unchanged since
[**2118**].
3. Extensive degenerative disease of the lumbar spine.
Brief Hospital Course:
Mr. [**Known lastname 94340**] is an 85-year-old male with invasive bladder
cancer and lung cancer, who is not pursuing aggressive treatment
who presents with severe, worsening leg pain secondary to lytic
lesion in prox femur.
.
#. Hip Fracture: A hip X-ray was done that showed lytic lesion
of femur and subsequent CT demonstrated extensive cortical
destruction of right femur and of left pubic symphysis. Patient
evaluated by ortho and XRT. Patient expressed he wanted to have
surgery. Ortho recommended partial hip replacement given the
significant destruction seen on CT. Preoperative risk assessment
was done by anesthesiology and nephrology, as well as by
obtaining an echocardiogram. Echo showed mild symmetric left
ventricular hypertrophy with hyperdynamic systolic function
without LVOT gradient as well as mild pulmonary artery systolic
hypertension. Patient was transfused with 3 units pRBC prior to
surgery.
.
The patient underwent R total hip hemiarthroplasy on [**2120-12-13**].
During the procedure he was hypotensive and had EBL of about
1000cc. He received 2 units of PRBCs and was briefly on
norepinephrine. Postoperatively he was admitted to the [**Hospital Unit Name 153**] for
monitoring. On presentation to [**Name (NI) 153**], pt. was A+O x 0. There was
concern that the patient may have focal neurological deficits on
right side, but those resolved quickly as the patient became
more oriented. Post-operatively, the patient was noted to have
poor UOP with hematuria that resolved. The patient also had
leukocytosis to WBC of 30, likely post-procedural stress and
trended downward. He was again trasnfused 1 additional unit of
pRBC with appropriate Hct response. The patient remained alert,
oriented, and hemodynamically stable and was transferred back to
the floor. He was seen by orthopedic surgery who recommended
Lovenox for 4 weeks, outpatient follow-up with Dr. [**Last Name (STitle) 5322**] and
touch down weight bearing for activity.
- Touch down weight bearing on Right leg
- Continue lovenox
- F/u with Dr. [**Last Name (STitle) 5322**]
.
# UTI - Urine cultures significant for MRSA infection sensitive
to vanc and bactrim. Patient initially started on bactrim but
was switched to vanc as renal function deteriorated (see below).
Patient completed a course of vanc for his UTI.
.
# Acute on Chronic RF - Patient had an elevated Cr and low UO
through nephrostomy tube. Patient's was evaluated by IR who saw
that the nephrostomy was displaced and had to be changed.
Nephrology was consulted who felt that his ARF was likely
post-obstructive, but could not rule out an element of AIN given
pos eos seen on smear. Patient was switched from bactrim to
vanc and lasix was held. Cr trended downward and patient
maintained good urine output through replaced nephrostomy.
Post-operatively, patient was found to have hematuria (as stated
above), that resolved. His Cr elevated again, thought to be
secondary to blood loss from surgery and ATN. Patient
maintained good urine output and Cr trended downward. Cr on
discharge was 1.9. Lasix was restarted prior to discharge.
.
#. Anemia: Managed with blood transfusion as stated above.
Patient was not restarted on his home aranesp.
- Check weekly hematocrit; Transfuse 1u pRBC if hct <25
Medications on Admission:
lipitor 40
aranesp q2 weeks
proscar 5
lasix 20 daily
metoprolol 25 [**Hospital1 **]
MVI
lidocaine patch
advil 600mg [**Hospital1 **] prn
tylenol #3 prn
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 10283**] Center - [**Location (un) **]
Discharge Diagnosis:
Primary: Metastatic Bladder Cancer to the bone
Discharge Condition:
Stable
Discharge Instructions:
You were seen in the hospital because of your leg pain. We saw
that you had bone destruction to your femur which was causing
your leg pain. You agreed to have surgery for this problem.
We made the following changes to your medications:
1. We are treating your pain with tylenol, lidocaine patch, and
morphine. You do not need to take tylenol #3.
2. We started you on senna, colace, biscodyl, mylanta
3. We started you on omeprazole
4. We did not continue your aranesp, please talk to your
physician before restarting this.
If you experience fevers >101, worsening pain, nausea, vomiting,
or any concerning symptoms please contact your PCP.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 5322**] on [**2121-1-9**] at 1:40pm. She is
on the [**Location (un) 1773**] of the [**Hospital Ward Name 23**] Building [**Hospital Ward Name 516**]. Her
number is ([**Telephone/Fax (1) 2007**].
[**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]
Completed by:[**2120-12-24**]
|
[
"5849",
"5990",
"41401",
"2724",
"2767"
] |
Admission Date: [**2106-12-31**] Discharge Date: [**2107-1-7**]
Date of Birth: [**2035-6-7**] Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / Latex
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Brain mass
Major Surgical or Invasive Procedure:
[**2107-1-3**]: Left frontal craniotomy
History of Present Illness:
71 yoM with significant cardiac history presented to [**Hospital3 2568**]
after 4 day history of worsening 'short term memory loss' and
all around mental status changes. No acute issues. No fevers,
chills, nausea or vomiting. Family brought him to ER for concern
of mental status changes.
At [**Last Name (un) 1724**] a Ct and an MRI reportedly showed a mass in the Left
frontal mass with mild mass effect on the falx, concern for GBM.
Past Medical History:
CAD s/p CABG in [**2097**], prostatic hypertrophy, recent SB
ischemia requiring ex lap and excision of distal ileum.
Social History:
electrical engineer, lives at home with wife and sons nearby.
Family History:
Noncontributory
Physical Exam:
T: 99.4 BP: 135/72 HR:82 R:24 O2Sats: 96% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**5-8**] B/L EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: [**Last Name (un) **]. S1/S2/s3/s4.
Abd: Soft, NT, BS+, scar c/w recent surgery
Extrem: cool and well-perfused. palp pulses B/L throughout
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: no objects at three minutes due to expressive aphasia
Language: expressive aphasia.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
2 mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-11**] throughout. No pronator drift
Sensation: Intact to light touch, pinprick bilaterally.
Toes downgoing bilaterally
ON DISCHARGE: his inicsion was clean, dry and intact. He has
very subtle word finding difficulty but was otherwise
neurologically intact.
Pertinent Results:
Cardiology Report ECG Study Date of [**2106-12-30**] 11:46:50 PM
Sinus rhythm. Prominent voltage consistent with left ventricular
hypertrophy. Small Q waves and T wave inversions in the inferior
leads. Cannot exclude old inferior myocardial infarction. Q
waves in the anteroseptal leads associated with ST segment
elevation in lead V1, probably secondary to left ventricular
hypertropy. Cannot exclude anteroseptal myocardial infaraction.
Diffuse ST-T wave abnormalities most likely related to left
ventricular hypertrophy. No previous tracing available for
comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
86 162 104 378/423 74 48 -158
Chest X-ray:
No evidence of congestive heart failure or pneumonia.
CT head [**2107-1-5**]
Status post left frontoparietal craniotomy with resection of
left frontal lobe mass. Slowed diffusion and thick peripheral
enhancement along the margin of the surgical cavity which
appears similar to the pre-operative examination is worrisome
for residual tumor; however, post-operative changes cannot be
excluded considering that the studying was performed 2 days
post-op. Recommend continued interval followup to evaluate
residual neoplasm.
Brief Hospital Course:
Mr [**Known lastname **] was admitted to Neurosurgery service for a new left
frontal mass approximately 7.8 by 5.5 x 5.8 cm. He was started
on steroids, loaded with Dilantin and admitted to our neurostep
down for close neurological observation. The patient has
significant cardiac history (post CABG and HOCM s/p) myomectomy
(both in [**2097**]) He had an echo [**2105-5-20**] with evidence of
asymmetric septal hypertrophy and had increase troponin on
admission so a cardiology consult was obtained they recommended
trending his tropon ins & beta blocker use. Once they were
decreasing or plateau he would be safe for surgery. On [**1-3**] he
went to the OR for a left sided craniotomy for mass
decompression. On the morning of [**1-4**], his mental status
appeared to wax and wane. Non-contrast head CT was repeated, and
showed a fair amount of continued vasogenic edema. In the
setting of this, his decadron was increased, and it was
determined for him to stay in the ICU for another 24hrs. He
had expressive dusphasia which considerable improved over time.
On the evening of [**1-4**], he transferred to [**Hospital Ward Name **] 11. MRI was
obtained on the morning of [**1-5**], which showed expected post op
changes, with some residual mass. He was seen by Neuro-Oncology,
and Brain tumor follow up arranged.
He was seen by PT/OT/Speech. It was felt that he was safe for Dc
to home with services and he was discharged on [**2107-1-7**]
Medications on Admission:
Phenytoin Sodium 300mg qDAY
Aspirin 81 mg PO/NG DAILY
Avodart 0.5 mg PO daily
Simvastatin 40 mg PO/NG DAILY
Dexamethasone 2 mg IV Q6H
Metoprolol Tartrate 200 mg PO/NG [**Hospital1 **]
Tamsulosin 0.4 mg PO HS
Discharge Medications:
1. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
3. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO daily ().
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*30 Tablet(s)* Refills:*2*
8. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Left frontal brain mass: pathology: prelim : Malignant Glioma
Discharge Condition:
Neurologically Stable
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
?????? You or a family member should inspect your wound every day and
report any of the following problems to your physician.
?????? Keep your incision clean and dry.
?????? You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
?????? Do NOT apply any lotions, ointments or other products to your
incision.
?????? DO NOT DRIVE until you are seen at the first follow up
appointment.
?????? Do not lift objects over 10 pounds until approved by your
physician.
DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery. Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.
MEDICATIONS:
?????? Take all of your medications as ordered. You do not have to
take pain medication unless it is needed. It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
?????? Do not use alcohol while taking pain medication.
?????? Medications that may be prescribed include:
o Narcotic pain medication such as Dilaudid (hydromorphone).
o An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? You were on a medication such as Aspirin, prior to your
surgery, you may safely resume taking this on one month post-op.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
?????? You are being sent home on steroid medication(tapering to 2mg
twice daily), make sure you are taking a medication to protect
your stomach (Prilosec, Protonix, or Pepcid), as these
medications can cause stomach irritation. Make sure to take
your steroid medication with meals, or a glass of milk.
ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
?????? Follow the activity instructions given to you by your doctor
and therapist.
?????? Increase your activity slowly; do not do too much because you
are feeling good.
?????? You may resume sexual activity as your tolerance allows.
?????? If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
?????? DO NOT DRIVE until you speak with your physician.
?????? Do not lift objects over 10 pounds until approved by your
physician.
?????? Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
?????? Do your breathing exercises every two hours.
?????? Use your incentive spirometer 10 times every hour, that you
are awake.
WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:
?????? Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
?????? Double, or blurred vision. Loss of vision, either partial or
total.
?????? Hallucinations
?????? Numbness, tingling, or weakness in your extremities or face.
?????? Stiff neck, and/or a fever of 101.5F or more.
?????? Severe sensitivity to light. (Photophobia)
?????? Severe headache or change in headache.
?????? Seizure
?????? Problems controlling your bowels or bladder.
?????? Productive cough with yellow or green sputum.
?????? Swelling, redness, or tenderness in your calf or thigh.
Call 911 or go to the Nearest Emergency Room if you Experience:
?????? Sudden difficulty in breathing.
?????? New onset of seizure or change in seizure, or seizure from
which you wake up confused.
?????? A seizure that lasts more than 5 minutes.
Important Instructions Regarding Emergencies and After-Hour
Calls
?????? If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
?????? Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.
Followup Instructions:
FOLLOW UP APPOINTMENT INSTRUCTIONS
??????Please return to the office in [**7-16**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner. If you are
discharged to a rehab facility, this may be done there as well.
Please make this appointment by calling [**Telephone/Fax (1) 2731**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2106-1-17**] at
4pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**] of
[**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. This is a
multi-disciplinary appointment. Their phone number is
[**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain as this was done during
your acute hospitalization
Completed by:[**2107-1-7**]
|
[
"5859",
"V4581",
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"53081"
] |
Unit No: [**Numeric Identifier 35416**]
Admission Date: [**2188-12-9**]
Discharge Date: [**2188-12-17**]
Date of Birth: [**2136-9-28**]
Sex: F
Service:
CHIEF COMPLAINT: Status post ventricular fibrillation at
rest.
HISTORY OF PRESENT ILLNESS: This is a 52-year-old female
with history of lung cancer status post right upper lobe
lobectomy, chronic vertigo, depression, heavy alcohol and
tobacco use, found down at home at 7:15 p.m. on the date of
admission by her husband, who had last spoken with the
patient at 2:30 p.m. on the day of admission. He found her
unresponsive and called 911 and began to initiate mouth-to-
mouth resuscitation. EMS arrived less than 5 minutes after
being called. They started CPR. The patient was shocked for
ventricular fibrillation with 200 followed by 300 followed by
360 jolts. She received epinephrine 1 mg IV x3, atropine 3
mg, and amiodarone 300 mg. She was sent to [**Hospital3 3583**]
Emergency Department. She was coded there again for PEA with
atropine 1 mg IV x1, epinephrine 1 mg IV x3. She also
received Narcan and thiamine. She was started on epinephrine
2 mcg per minute for hypertension with systolic blood
pressure in the 70s. She was also noted to be profoundly
hypothermic with a temperature of 88 degrees. She was avidly
rewarmed at [**Hospital1 46**] with CT x2 and bladder irrigation. Her
serum toxicity screen for positive for benzodiazepines, and
ethanol level was 434. She was transferred to [**Hospital1 346**] for further care.
PAST MEDICAL HISTORY: Lung cancer status post right upper
lobe lobectomy in [**2182**].
Vertigo.
Depression.
Alcohol abuse.
Pernicious anemia.
GERD status post "surgery" 2 to 5 years ago.
Carpal tunnel syndrome status post bilateral surgery.
Status post hysterectomy.
ALLERGIES: KLONOPIN AND SULFA.
MEDICATIONS ON ADMISSION:
1. Celexa 20 mg p.o. q.d.
2. Lorazepam 0.5 mg p.o. b.i.d.
3. Meclozine 25 mg p.o. t.i.d.
4. B12 injection every month.
SOCIAL HISTORY: History of alcohol abuse 1 to 2 pints per
week, with a history of binge drinking. Tobacco 1-pack-per-
day smoker.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 35.9, heart
rate 127, blood pressure 133/90, respiratory rate 16, oxygen
saturation 92 percent on room air. General: Covered with a
heating blanket, unresponsive middle-aged female. HEENT:
Pupils equal, dilated, unresponsive to light. Cardiac:
Tachycardic. Lungs: Equal breath sounds bilaterally.
Abdomen: Normoactive bowel sounds, soft. Extremities: No
edema noted. Neuro: Unresponsive without posturing.
Increased deep tendon reflexes bilaterally throughout with
equivocal Babinski reflexes bilaterally.
LABORATORY STUDIES ON ADMISSION: Sodium 144, potassium 4.6,
chloride 117, bicarbonate 8, BUN 14, creatinine 0.7, glucose
215, anion gap 19, white blood cell count 26.3, hematocrit
50.1, platelets 211,000, INR 1.4, blood gas 6.99/41/460,
lactate 10.7, and CK 1145. Chest x-ray without heart failure
or pneumonia. ALT 1733, AST 3581, alkaline phosphatase 190,
and total bilirubin 0.4.
EKG: Sinus rhythm at 93 with normal axis and poor R-wave
progression.
SUMMARY OF HOSPITAL COURSE: As mentioned above, when the
patient was admitted, she was unresponsive. A Neurology
consult was obtained, who felt that her condition was
consistent with hypoperfusion and hypoxic brain damage from
cardiac arrest. On neurologic examination, she still had
some evidence of brain stem function. Her EEG showed burst-
suppression, no response to stimulation, consistent with
diffuse brain damage. She was noted to make jerking
movements, which were felt to be myoclonic jerks secondary to
hypoxic injury rather than seizures. Given her poor
neurologic status, marked acidosis, with evidence of multiple
organ system damage (heart, liver), a family meeting was held
to discuss goals of care. Following the family's decision to
make the patient comfort measures only, she was withdrawn
from the ventilator on [**2188-12-15**], and vital signs and blood
draws were stopped. She was treated with a morphine drip and
scopolamine p.r.n. A Palliative Care consultation was
obtained on [**2188-12-16**]. The organ bank was contact[**Name (NI) **] by her
primary care team, and she was deemed to not be a candidate
for organ transplantation given the fact that she was no
longer intubated. On [**2188-12-17**], the patient stopped
breathing. Her pupils were noted to be fixed, entirely dead,
and no respiratory effort was noted after 5 minutes of
observation. She was not responsive to painful stimulus.
Her family was notified, who declined a postmortem. The
attending, Dr. [**First Name (STitle) **], was present at the time of death, 3:25
p.m., [**2188-12-17**].
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 20070**]
Dictated By:[**Last Name (NamePattern1) 23132**]
MEDQUIST36
D: [**2189-8-19**] 15:10:49
T: [**2189-8-19**] 23:48:37
Job#: [**Job Number 35417**]
|
[
"51881",
"5845",
"53081",
"311"
] |
Unit No: [**Numeric Identifier 75278**]
Admission Date: [**2186-10-5**]
Discharge Date: [**2186-10-15**]
Date of Birth: [**2186-10-5**]
Sex: F
Service: NB
HISTORY: Baby girl [**Known lastname 805**] is a 2.055 kg product of a 32
2/7 weeks gestation born to a 37-year-old G-5, P-4, now 6
mother. Prenatal screens: O+, antibody negative, hepatitis
B surface antigen negative, rubella immune, RPR nonreactive,
GBS positive. Mother presented to [**Name (NI) **] [**Last Name (NamePattern1) **] Hospital in
labor. Membranes were intact. Due to positive GBS status,
she was started on Penicillin.
Antenatal history notable for IVF twin gestation with
normal anatomic survey for both twins. Has chronic
hypertension treated with Labetalol and hypothyroidism
treated with Thyroxine. Mother was betamethasone complete at
the time of delivery. Due to premature delivery and high
risk, she was transferred to [**Hospital3 **] for delivery.
Ruptured membranes for this twin was at 07:29 a.m. and with
clear fluid. Infant was delivered vaginally with initially
limp, cyanotic with poor respiratory effort. She was given
blow by O2 and then bag mask CPAP for several minutes. Apgars
were 7 at one and 7 at five minutes respectively.
PHYSICAL EXAMINATION AT DISCHARGE: Awake and alert, in
isolette, swaddled. Anterior fontanel open and flat with
mild cephalo molding breath sounds clear and equal on room
air with mild retractions and comfortable respirations. No
audible murmur. Well perfused with normal pulses. Abdomen
soft and round with active bowel sounds. No masses. Normal
female genitalia for gestational age.
HISTORY OF HOSPITAL COURSE BY SYSTEMS:
Respiratory: Baby was admitted to the newborn intensive care
unit requiring prolonged CPAP. She remained on CPAP for a
total of 4 days at which time she transitioned to room air and
has been stable on room air since that time. She was treated
with caffeine citrate for management of apnea and bradycardia
of prematurity. She is currently receiving 16 mg p.o. q. day
at 12:30 in the afternoon.
Cardiovascular: She has been cardiovascularly stable without
issue.
Fluid and electrolyte: Her birth weight was 2.055 kg. Her
head circumference was 31.5 cm and her length was 33.5 cm.
Discharge weight 1895 grams. Discharge head circumference
30.5 cm. Discharge length 44 cm. Infant was initially
started on 80 cc/kg per day of D10W. Enteral feedings were
initiated on day of life #2. Infant has achieved full enteral
feedings and is currently tolerating 150 cc/kg per day of
breast milk 26 calorie or premature Enfamil 26 calorie.
GI: Her peak bilirubin was on day of life #3 of 12.0/0.4.
She was treated with photo therapy and the issue has resolved.
Rebound biliirubin was 5.4/0.3.
Infectious disease: CBC and blood culture were obtained on
admission. CBC was benign and blood cultures remained
negative at 48 hours, at which time Ampicillin and gentamycin
were discontinued.
Hematology: Blood type is O+, direct Coombs negative.
Initial hematocrit was 49. Infant has not required blood
products.
Neuro: Infant has been appropriate for gestational age.
Sensory: Hearing screen has not been performed, but should be
done prior to discharge to home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Hospital.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 75275**], telephone number [**Telephone/Fax (1) 75279**].
CARE RECOMMENDATIONS: Continue 150 cc/kg of breast milk 26
calorie or premature Enfamil 26 calorie to maintain weight
gains of 30 grams/kg per day. Car seat position screening
has not been performed.
MEDICATIONS: Infant is currently receiving caffeine citrate
16 mg p.o. q. day at 12:30 in the afternoon (8 mg/kg per
day).
State newborn screen was sent on [**2186-10-8**] with
elevated 17OHP. Repeat was sent on [**2186-10-13**] and is
pending.
IMMUNIZATIONS: The infant has not received any immunizations
to date.
DISCHARGE DIAGNOSES:
Former 32 and 2/7 weeks twin
Respiratory distress syndrome treated with CPAP only
Rule out sepsis with antibiotics
Apnea and bradycardia of prematurity on caffeine
Mild hyperbilirubinemia, treated
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 54936**]
Dictated By:[**Last Name (NamePattern1) 75280**]
MEDQUIST36
D: [**2186-10-15**] 21:23:35
T: [**2186-10-16**] 09:19:05
Job#: [**Job Number 75281**]
|
[
"7742",
"V290"
] |
Admission Date: [**2159-12-4**] Discharge Date: [**2159-12-7**]
Date of Birth: [**2077-3-7**] Sex: M
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**Last Name (NamePattern1) 1136**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Intubation
Hemodialysis
History of Present Illness:
82 y/o male ESRD on HD, DM, HTN admitted after presenting with
shortness of breath to dialysis. He was unable to be dialyzed
and was sent to the ED.
While in the ED, he was noted to have elevated JVP, pulmonary
edema. In addition, he was noted to be 6.8kg above his dry
weight. Initial vital signs were T-97.1, HR-58, BP-110/58, SaO2-
100% on RA. He received 3 dosees of SL NTG, lasix 40mg IV x 1
and placed on a non-invasive breathing mask. His tidal volumes
were into the 150s and patient seemed to be in respiratory
distress. He was intubated and admitted to the MICU. Renal was
consulted for urgent dialysis. He underwent HD yesterday and
4.5L of fluid was removed. Patient was stablized and extubated.
He remained hemodynamically stable. Given his current condition,
he was transferred to the floor for further care.
Past Medical History:
ESRD
Diabetes
Hypertension
Hypercholesterolemia
Asthma/COPD?
Social History:
Lives with friend who takes care of him. has son who is also
involved in care. Denies ETOH or tobacco. Otherwise unable to
obtain
Family History:
NC
Physical Exam:
VITAL SIGNS:
T=98.9 BP=174/64 HR=80 RR=22 O2=100% on 2L
.
.
PHYSICAL EXAM
GENERAL: Pleasant, well appearing male in NAD
HEENT: JVD- 10cm. No LAD. Moist mucous membranes. Normocephalic,
atraumatic. No conjunctival pallor. No scleral icterus. OP
clear. Neck Supple, No LAD.
CARDIAC: Regular rate and rhythm. No m/r/g. Normal S1, S2. JVP=
10cm
LUNGS: Decreased breath sounds at bases with right-sided
crackles. Good air movement bilaterally- no signs of respiratory
distress at this time.
ABDOMEN: Obese. +bs, soft, NT/ND.
EXTREMITIES: 2+ edema in b/l LE. No calf pain. 2+ dorsalis
pedis/ posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved
sensation throughout. 5/5 strength throughout. [**12-29**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
Admission labs
[**2159-12-4**] 12:30PM BLOOD WBC-8.8 RBC-4.18* Hgb-12.2* Hct-37.1*
MCV-89 MCH-29.2 MCHC-32.9 RDW-15.9* Plt Ct-224
[**2159-12-4**] 12:30PM BLOOD PT-12.7 PTT-76.7* INR(PT)-1.1
[**2159-12-4**] 12:30PM BLOOD Glucose-172* UreaN-28* Creat-4.7* Na-137
K-3.8 Cl-97 HCO3-32 AnGap-12
[**2159-12-4**] 12:30PM BLOOD cTropnT-0.04*
[**2159-12-6**] 06:20AM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2159-12-4**] 12:30PM BLOOD Albumin-3.4 Calcium-7.5* Phos-5.1* Mg-1.9
[**2159-12-4**] 12:36PM BLOOD Type-[**Last Name (un) **] pO2-113* pCO2-67* pH-7.29*
calTCO2-34* Base XS-2 Comment-GREEN TOP
[**2159-12-4**] 12:36PM BLOOD Glucose-166* Lactate-1.2 Na-134* K-3.8
Cl-93*
[**2159-12-4**] 09:27PM BLOOD Type-ART FiO2-40 pO2-79* pCO2-58* pH-7.42
calTCO2-39* Base XS-10 Intubat-INTUBATED Vent-SPONTANEOU
Discharge Labs
[**2159-12-7**] 06:00AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.0
[**2159-12-7**] 06:00AM BLOOD Glucose-38* UreaN-21* Creat-3.7*# Na-142
K-3.4 Cl-100 HCO3-32 AnGap-13
[**2159-12-7**] 06:00AM BLOOD WBC-6.9 RBC-4.21* Hgb-12.1* Hct-37.0*
MCV-88 MCH-28.8 MCHC-32.7 RDW-16.1* Plt Ct-207
TTE:The left atrium is normal in size. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
right ventricular free wall is hypertrophied. The aortic root is
mildly dilated at the sinus level. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a fat pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Diastolic dysfunction. Dilated aortic sinus.
CXR [**2159-12-6**]:
Comparison is made with prior study performed a day earlier.
Improve left retrocardiac opacity consistent with improving
atelectasis, there are new plate-like atelectasis in the right
mid lung; right lower lobe aeration has also improved.
Cardiomediastinal contours are unchanged, small bilateral
pleural effusions are stable, there is no pneumothorax. Mild
pulmonary edema is stable.
Brief Hospital Course:
82yo male with ESRD on HD, HTN, DM2 admitted for shortness of
breath
1. Pulmonary Edema with acute on chronic diastolic heart
failure:
Patient admitted with SOB [**1-29**] pulmonary edema and volume
overload which improved with hemodialysis on his usual schedule.
Per discussion with renal, it is possible they were
underdialyzing him and he needs more agressive dialysis. He was
continued on his usual HD schedule here (T/Th/Sat) and was
extubated without difficulty and satting mid to high 90s on room
air at time of discharge. He had an ECHO which revealed "Mild
symmetric left ventricular hypertrophy with preserved global and
regional biventricular systolic function and diastolic
dysfunction. Since he was mildly hypertensive, his [**Last Name (un) **] was
uptitrated. He was ruled out for MI. He should continue on low
salt cardiac diabetic renal diet to avoid issues with volume
overload in the future.
2. Respiratory Failure:
Improved as above with dialysis. He did not have any focal
infiltrates or fever to suggest leukocytosis. He was also given
albuterol and ipratropium nebs as needed for wheezing as he is
on Advair but he is unsure why he is on this medication.
3. COPD/Asthma:
Patient continued to wheeze during his admission. Unclear
pulmonary history and PCP was on vacation so we were unable to
obtain further information regarding his pulmonary status. He
was continued on advair and albuterol/ipratropium nebs.
4. Hypercholesterolemia: Continued Simvastatin at home dose
5. Hypertension: Continued amlodipine, labetalol, valsartan.
Patient on olmesartan at home but substituted for valsartan in
house. Valsartan increased to 160mg daily.
6. ESRD on HD: He was continued on his hemodialysis on
Tu/Thurs/Sat schedule.
7. Type 2 Diabetes Mellitus, uncontrolled and with
complications: Continue insulin + SS. Lantus dose decreased at
night for low blood sugar in am [**2159-12-7**]
8. Diarrhea: Pt was having loose stools on [**2159-12-7**]. C. diff
toxin was ordered but not sent. He should have C diff checked if
diarrhea recurs although he has not been on antibiotics here and
did not have a leukocytosis.
Medications on Admission:
NephroVites 1
Simvastatin 20 QHS
Trazadone 20 QHS
IC Amlodipine 10 Daily
Labetolol 600 [**Hospital1 **]
Olmesartan 20mg Daily
Renagel 400mg TID prior to meals
Lantus 8U daily
Advair
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Labetalol 200 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
6. Sevelamer HCl 400 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q 24H (Every
24 Hours).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) NEB Inhalation Q4H (every 4 hours) as
needed for SOB, wheezing.
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB, wheezing.
11. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. Olanzapine 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed for agitation.
13. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for bloating.
14. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
15. Insulin sliding scale
Please follow attached sliding scale. Fixed dose of lantus- 4U
every night
16. Olmesartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Primary: Diastolic heart failure, End-stage kidney disease (on
hemodialysis)
Secondary: Diabetes Mellitus
Discharge Condition:
Good. Vital signs stable.
Discharge Instructions:
You were admitted to the hospital with shortness of breath.
While here, it was found that you were fluid overloaded for
unclear reasons. You underwent dialysis with an improvement in
your symptoms. An ultrasound of your heart showed mild
dysfunction. Because of this, it is important that you limit
your fluid and salt intake. Your symptoms improved and you did
well while here. You worked with physical therapy who
recommended that you should go to rehab when you got discharge
to build up strength. Upon discharge, you no longer complained
of respiratory problems.
The following changes were made to your medications:
1. Stop taking your trazadone
2. Decrease your lantus to 4U everynight
3. Please start taking famotidine 20mg by mouth every day
4. Please start taking ipratropium nebs every 6 hours as needed
for shortness of breath/wheezing
5. Please start taking albuterol nebs every 4 hours as needed
for shortness of breath/wheezing
6. Increase your dose of olmesartan to 40mg by mouth daily
7. Please take olanzapine 2.5mg by mouth twice a day as needed
for agitation
Followup Instructions:
Resume regular dialysis schedule on discharge
Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 803**]
[**Last Name (NamePattern1) **], in [**12-29**] weeks. You can contact her at [**Telephone/Fax (1) 82786**]
Completed by:[**2159-12-8**]
|
[
"51881",
"40391",
"2720",
"4280"
] |
Admission Date: [**2150-3-11**] Discharge Date: [**2150-3-14**]
Date of Birth: [**2150-3-11**] Sex: F
Service: NB
HISTORY: Baby Girl [**Known lastname **] was born weighing 3380 grams at 41-
weeks gestation. She was born to a 19-year-old G2, P0 now 1
mother with an [**Name (NI) 37516**] of [**2150-3-4**]. Prenatal labs were
blood type O-positive, antibody negative, RPR nonreactive,
HBsAg negative, rubella immune, GBS negative. This pregnancy
was uncomplicated. Intrapartum course was complicated by
maternal fever to 99.2 degrees with fetal tachycardia with
heart rates 160s-180s, failure to progress, meconium stained
amniotic fluid. Due to these concerns, the mother was taken
for a [**Name (NI) 32007**] delivery. She did not receive intrapartum
antibiotics prophylaxis.
At delivery, the infant emerged with moderate tone and no
respiratory effort. Meconium stained amniotic fluid was
noted. The infant was intubated and suctioned with no meconium
seen below the vocal cords. The infant was then
resuscitated with vigorous stimulation, oxygen, and positive
pressure ventilation for 1-2 minutes. With gradual
improvement in tone and respiratory effort and color, the
positive pressure ventilation was stopped. By 5-6 minutes of
age, the infant was pink and vigorous on room air. Apgar
scores were 5, 8, and 9 at 1, 5, and 10 minutes respectively.
The infant was admitted to the NICU to evaluate for sepsis
due to maternal fever and fetal tachycardia, with no antibiotics
during labor.
PHYSICAL EXAMINATION ON ADMISSION: Showed an active and
vigorous term infant in no distress. HEENT: Moderate molding
and occipital caput. Fontanels were soft and flat. Ears
and nares were normal. Palate: Intact. Neck: Without lesions.
Chest: Clear and equal, no grunting, flaring, or retracting.
Cardiac: Normal rate and rhythm, no murmur. Abdomen: Soft, no
hepatosplenomegaly, no masses, active bowel sounds. GU:
Normal female with patent anus. Extremities, back, and hips:
Normal. Neuro: Appropriate tone and activity, no jittery.
Weight 3.88 kilograms which is greater than 90th percentile,
length 52 cm which is 75th-90th percentile, head
circumference 36.5 cm which is greater than 90th percentile.
HOSPITAL COURSE BY SYSTEMS: Respiratory: On admission to the
NICU, the infant did have a requirement for oxygen with some
desaturations and mild work of breathing. Nasal cannula was
initiated at 100 cc per minute flow. On day of life 1, the
infant weaned off of nasal cannula to room air and has
remained on room air since that time with respiratory rates
in the 20s-40s range. No apnea spells, no desaturations, or
bradycardia has been noted.
Cardiovascular: The infant has remained hemodynamically
stable with a normal heart rate and blood pressure and no
murmur.
Fluid, electrolytes, and nutrition: The infant was made NPO
on admission and was started on IV fluids of D10W. Enteral
feedings were initiated on the newborn day and the infant was
allowed to ad-lib p.o. feed. The infant weaned off IV fluid
by day of life 2 and was all ad-lib p.o. feeding. The initial
D-stick on admission was 20. The baby was treated with a [**Name (NI) 44084**]
bolus and IV fluids were initiated. The D-sticks slowly
rose and the infant slowly weaned off of IV fluids as
p.o. feeds were increased to keep the D-sticks in
the normal range. No electrolytes have been measured on this
baby and at present, the infant is ad-lib p.o. feeding of
Enfamil 20 with iron and taking adequate volume with no concerns.
Hematology: A hematocrit on admission was 56.9. Most recent
hematocrit was 63.8 on day of life 2 which is [**2150-3-13**]. The infant has required no blood product transfusion.
Infectious disease: CBC and blood culture were screened on
admission. The CBC was benign with 0 bands, no left shift.
Ampicillin and gentamicin were given for 48 hours. Blood
culture remained negative at 48 hours, and antibiotics were
discontinued at that time. The infant has showed no signs of
sepsis since. Follow-up CBC was done on day of life 2 which
is also benign.
Neurology: The infant has shown signs of irritability since
admission to the NICU. No jitteriness or seizures have been
observed and other than the irritability, the infant has
had a normal neurologic exam. Will need to be followed by primary
pediatrician regarding this irritability in setting of need for
some degree of delivery room resuscitation
Sensory: Infant will need a hearing screen prior to discharge
from the hospital.
Psychosocial: The [**Hospital1 18**] social worker has been involved with
the family. There are no active issues at this time. If there
are any social work concerns, social worker can be reached at
[**Telephone/Fax (1) **].
Condition at trasnfer to Newborn Nursery is good.
DISCHARGE DISPOSITION: [**Hospital **] transferred to the
normal newborn nursery on [**2150-3-14**].
NAME OF PRIMARY PEDIATRICIAN: Undecided at this time. (Will be
admitted onto [**Doctor Last Name 46742**] Newborn Service)
CARE AND RECOMMENDATIONS: Ad-lib p.o. feedings of E20 with
iron or breastfeed. No medications. State screen will need to
be sent prior to discharge, on [**2150-3-14**]. Infant has not
received a hepatitis B vaccine at this time.
DISCHARGE DIAGNOSES: Respiratory distress, negative sepsis
evaluation, hypoglycemia, and possible mild perinatal depression.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 58754**]
Dictated By:[**Name8 (MD) 62299**]
MEDQUIST36
D: [**2150-3-13**] 21:49:58
T: [**2150-3-14**] 04:54:34
Job#: [**Job Number 64988**]
|
[
"V290"
] |
Admission Date: [**2116-4-27**] Discharge Date: [**2116-4-30**]
Date of Birth: [**2062-9-7**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Demerol
Attending:[**First Name3 (LF) 7616**]
Chief Complaint:
fever, abdominal pain, N/V
Major Surgical or Invasive Procedure:
Midline placement in left arm
ERCP with stent placement
History of Present Illness:
53yo F with alcoholic cirrhosis s/p OLT on immunopsuppression,
h/o CM (EF 15%-->50%), atrial fibrillation, DM2, HTN,
hypothyroidism, who was admitted from liver clinic with fever,
vomiting and diarrhea since Saturday. Her fever was 104.7 at
11pm on Sunday morning, and 102 on day of admission.
.
Patient's sx started with the "worst headache of her life" with
associated nausea, vomiting, and watery diarrhea. Patient also
noted lower abdominal cramping, RUQ pain and tenderness, which
is similar to past episodes of anastomatic biliary stricture
relieved by biliary stent placement, last placed in [**2116-2-9**]
and due to be exchanged in [**Month (only) 547**].
.
Past Medical History:
1. s/p OLT- [**1-11**], for EtOH cirrhosis, c/b postop CHD stricture
s/p multiple stents last placed in [**2116-2-9**].
a. c/b portal HTN, thrombocytopenia, slowly increasing alk phos
b. s/p ERCP and new biliary stent on [**2115-6-21**]: anatstamotic
stricture 3 mm c/w post-op stricture, 6 mm stone in lower [**2-11**] of
CBD, extracted adn 9 cm and 7 cm stent in common hepatic duct
2. idiopathic cardiomyopathy- EF <20% in [**5-13**], EF 50% in [**9-12**],
followed by Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**], s/p AICD/VVI ppm
3. DM2- on Lantus
4. Hypothyroidism
5. h/o UGIB
6. RV perf after R heart bx s/p drain
7. AF with RVR
8. hyperkalemia s/p aldactone
9. pulmonary infiltrate on chest CT
10. hypertension
11. h/o UGIB and LGIB in [**2111**] with EGD with varicies, ? banded
12. h/o low back pain
13. s/p tubal ligation in [**2093**]
Social History:
Social History:
Lives with husband at home.
Tobacco ?????? [**3-14**] cigarettes/day.
EtOH ?????? Stopped drinking on [**3-14**],
previously [**4-11**] vodka drinks per day for 30 years.
No IVDA
Family History:
Strong hx of alcohol abuse and cirrhosis. Father died from MI at
53. Mother died at 57 from alcohol abuse, brother died in the
last two years from alcohol abuse
Physical Exam:
VS: T98.9 BP 125/76 HR 98 RR 20 O2sat 100% RA BS 277
Gen: fatigued and chronically ill appearing female
Skin: Multiple ecchymoses over arms
HEENT: MMM. PERRL. Sclera anicteric.
Neck: Supple. Full ROM. No cervical LAD.
Hrt: Tachycardic. Regular rhythm. No murmurs, rubs, or gallops.
Lungs: Equal breath sounds throughout. No rales rhonchi or
wheezes
Abd: S/ND. Tenderness to deep palpation over RUQ with guarding.
No organomegaly. Cholecystectomy scar.
Ext: WWP. No CCE
Neuro: CN2-12 intact. Alert and oriented x3. [**6-12**] strenght
throughout. Limited ROM with flexion/extension in right
shoulder. Minimal erythema and swelling over shoulder. 2+DTRs.
[**Name (NI) **] asterixis.
Pertinent Results:
[**2116-4-27**] ALT(SGPT)-146* AST(SGOT)-109* LD(LDH)-298* CK(CPK)-103
ALK PHOS-297* AMYLASE-32 TOT BILI-0.5
[**2116-4-27**] LIPASE-8
[**2116-4-27**] CK-MB-2 cTropnT-<0.01
[**2116-4-27**] PT-31.6* PTT-41.1* INR(PT)-3.4*
[**2116-4-27**] LACTATE-3.6*
[**2116-4-30**] INR 1.1, ALT 57, AST 18, ALK PHOS 161, AMYLASE 12,
LIPASE 13, TBILI 0.4
.
Rapamycin levels - 15.1, 8.1, 11.2, 7.1 for [**Date range (3) 57856**]
.
[**2116-4-27**] 12:40PM URINE BLOOD-LG NITRITE-NEG PROTEIN-500
GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-TR
[**2116-4-27**] 12:40PM URINE RBC-21-50* WBC-[**7-18**]* BACTERIA-MOD
YEAST-MOD EPI-[**12-28**] TRANS EPI-[**4-12**]
[**2116-4-27**] URINE HOURS-RANDOM UREA N-404 CREAT-124 SODIUM-65
.
URINE CULTURE (Final [**2116-4-29**]): NO GROWTH.
.
FECAL CULTURE (Final [**2116-4-29**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2116-4-29**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2116-4-28**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2116-4-29**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
.
CMV Viral Load (Final [**2116-4-30**]): CMV DNA not detected.
.
[**2116-4-27**] 12:50 pm BLOOD CULTURE
AEROBIC BOTTLE (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 8 R
CEFTAZIDIME----------- PND
CEFTRIAXONE----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- 32 I
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
.
ERCP REPORT:
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: 2 plastic stents placed in the biliary duct were
found in the major papilla. Evidence of a previous
sphincterotomy was noted in the major papilla.
Cannulation: Cannulation of the biliary duct was successful and
deep with a balloon catheter using a free-hand technique.
Contrast medium was injected resulting in complete
opacification. The procedure was not difficult. Cannulation of
the pancreatic duct was not attempted.
Biliary Tree: A single irregular stricture of benign appearance
was seen at the middle third of the common bile duct. There was
no post-obstructive dilation. These findings are compatible with
anastomotic stricture.
Procedures: Both plastic stents were removed from the common
bile duct. Small amount of soft sludge came out on stent
extraction.
Two 10F Cotton [**Doctor Last Name **] biliary stents (7cm and 8cm) were placed
successfully in the common bile duct.
Impression: 2 Stents in the major papilla - evidence of prior
sphincterotomy
Residual anastomotic stricture
Two new stents replaced
.
GALLBLADDER/LIVER U/S WITH DOPPLER:
The hepatic veins are patent with appropriate directionality of
flow and normal-appearing waveforms. The portal veins are
patent with hepatopetal flow. The left hepatic artery is patent
with a resistive index of 0.41-0.46. There appears to be a good
systolic upstroke of the waveform. The right hepatic artery is
patent with a resistive index of 0.4 with good systolic
upstroke. The main hepatic artery is patent with resistive
index of 0.48-0.51. Biliary stents appear to be in place. No
intrahepatic biliary ductal dilatation is appreciated.
IMPRESSION: Patent hepatic vasculature with resistive indices
as above. No intrahepatic biliary ductal dilatation is
appreciated.
.
CXR ON ADMISSION: An ICD remains in place with the lead in the
right ventricle. The heart size is normal. The lungs
demonstrate scarring at the right lung base adjacent to the
hemidiaphragm. There are no focal areas of consolidation and no
pleural effusions are evident. Deformity of a lower thoracic
vertebral body and mild compression of an upper lumbar vertebral
body are without interval change. With regard to the right
basilar scarring, it is located at a site of a pre-existing more
confluent area of opacity. IMPRESSION: 1) No evidence of
pneumonia. 2) Linear scarring right lower lobe.
.
NON-CONTRAST HEAD CT SCAN: There is no evidence of acute
intracranial hemorrhage or shift of the normally midline
structures. The ventricles and cisterns are normal. The density
values of the brain parenchyma are normal, with preservation of
the [**Doctor Last Name 352**]-white matter differentiation. The visualized paranasal
sinuses and mastoid air cells are clear. Osseous and soft tissue
structures are unremarkable. IMPRESSION: No evidence of acute
intracranial hemorrhage. No change from [**2115-11-9**]
.
ECG [**2116-4-27**]: Sinus tachycardia and frequent atrial ectopy.
Diffuse low voltage. Prior myocardial infarction. Prior
anteroseptal myocardial infarction. Compared to the previous
tracing of [**2115-9-14**] the rate has increased and frequent atrial
ectopy has appeared as well as ventricular ectopy. Followup and
clinical correlation are suggested.
.
ECG [**2116-4-28**]: Sinus rhythm with slowing of the rate as compared
to the previous tracing of [**2116-4-27**]. Low limb lead voltage.
Prior anteroseptal myocardial infarction. No diagnostic interim
change.
.
PICC PLACEMENT: The right upper arm was prepped in a sterile
fashion. Since no suitable superficial vein was visible,
ultrasound was used for localization of a suitable vein. The
basilic vein was entered under ultrasonographic guidance with a
21-gauge needle. Hard copies of ultrasound images were obtained,
documenting patent vein before and after establishing access. A
0.018 guidewire was advanced under fluoroscopy into the superior
vena cava. Based on the markers on the guidewire, it was
determined that a length of 30 cm would be suitable. The PICC
line was trimmed to length and advanced over a 4-French
introducer sheath under fluoroscopic guidance into the
brachiocephalic vein. The sheath was removed. The catheter was
flushed. A final chest x-ray was obtained demonstrating the tip
in the brachiocephalic vein as ordered as a midline PICC. The
line is ready for use. A Statlock was applied and the line was
hep-locked. IMPRESSION: Successful placement of a 30-cm total
length PICC line with the tip in the brachiocephalic vein, ready
for use.
.
ECHO: The left atrium is dilated. The right atrium is moderately
dilated. There is symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Right ventricular
chamber size is mildly dilated and free wall motion is normal.
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The ascending aorta is
mildly dilated. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is a small Pericardial effusion.
There are no echocardiographic signs of tamponade. No vegetation
seen (cannot exclude). Compared to the prior study of [**9-/2115**],
there is no significant change.
.
Brief Hospital Course:
## Cholangitis secondary to biliary stricture with biliary
sepsis -- Patient presented with fever to 104, RUQ, cholestatic
picture on LFTs, and history of recurrent biliary strictures
with stent placements. She was transferred to the MICU for
hypotension (BP 78/54), fever, elevated lactate 3.6, and
concerns for ascending cholangitis, as well as acute renal
failure and coagulopathy. Patient was oliguric as well, with
20cc of urine over 1.5 hours. She was given IVF and empirically
covered with vancomycin and meropenem, and given stress dose
steroids. She was also given vitamin K and FFP to reverse her
coagulopathy. Patient was then taken to ERCP, where biliary
stents were placed, relieving the obstruction. Her LFTs trended
downwards and amylase and lipase were WNL. She was continued on
the meropenem for panresistant E. coli from blood culture. A
midline was placed for home antibiotic administration. TTE was
negative for vegetations. Stress-dose steroids were weaned and
blood sugar control was tightened. She will need a repeat ERCP
in [**5-13**] weeks and may need surgery for biliary duct dilatation
for permanent relief of strictures.
.
## Headache -- Her headache persisted after ERCP. She did not
have any meningeal signs but did complain of some photophobia.
She was given Dilaudid, Sudafed, and Percocet with good effect
and headache had resolved by time of discharge.
.
## ARF -- Cr 1.9 from baseline 0.9, decreased to 0.8 with IVF,
FeNa nondiagnostic in context of furosemide but FeUrea 2.84%,
consistent with prerenal failure. Patient's medications were
renally dosed while in acute renal failure.
.
## s/p OLT -- Rapamune, mycophenolate mofetil, and prednisone
were continued. Rapamune levels were monitored daily and dosed
accordingly. Bactrim was continued for PCP [**Name Initial (PRE) 1102**]. She was
discharged home on rapamune 2 mg po qd, to be followed up in
clinic.
.
## Post-transplant diabetes -- She was controlled with insulin
glargine 16 units at night and regular insulin with tightened
sliding scale in the context of stress-dose steroids.
.
## Atrial fibrillation -- Coumadin was held for ERCP and
restarted after procedure on home dose. INR subtherapeutic on
discharge (1.1).
.
## Dilated cardiomyopathy -- Echo this admission showed EF
55-60%, no evidence of vegetations. Digoxin, hydralazine,
lasix, and imdur were held for hypotension. Carvedilol was
maintained. She will need her antihypertensives readded at an
outpatient visit when her blood pressures have stabilized.
.
## Urinary tract infection -- Patient also had positive
urinalysis, with fecal contamination on urine culture. Repeat
urine culture was negative.
.
## Diarrhea -- Patient noted diarrhea, nonbloody and nonmucousy.
C. diff negative x 2. Stool culture was negative for
salmonella, shigella, campylobacter.
.
## Brachial plexus injury -- From past PICC placement in [**2115**].
Neurontin was continued at renal dosage.
.
## Hypothyroidism -- Stable. She was kept on home-dose
levothyroxine.
.
## PPx -- Patient was on coumadin and given a PPI. She was seen
by PT and OT.
.
## Code: She remained FULL code. Patient was discharged home
with services.
Medications on Admission:
Outpatient meds:
Sirolimus 3mg qd
Mycophenolate mofetil 1000mg [**Hospital1 **]
Prednisone 5mg qd
Bactrim DS 1 tab qd
Coumadin 6mg qhs
Carvedilol 6.25mg qd
Digoxin 0.125mg qd
Hydralazine 50mg tid
Furosemide 20mg qd
Imdur 60mg qd
Levothyroxine 100mcg qd
Lantus 12U qhs
RISS
Neurontin 300mg qam/noon, 600mg qhs
Celexa 10mg qd
Xanax 0.5mg prn anxiety
Caltrate 1200mg qhs
Perocet 1-2tabs q6h prn pain
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
5. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO three times
a day.
7. Alprazolam 0.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) as needed.
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Sirolimus 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
13. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily).
14. Midline care
Midline care per protocol
15. Insulin Glargine 100 unit/mL Cartridge Sig: Sixteen (16)
units Subcutaneous at bedtime.
16. Meropenem 1 g Recon Soln Sig: One (1) Intravenous three
times a day for 10 days.
Disp:*30 * Refills:*0*
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for headache. Tablet(s)
18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Sliding
Scale Subcutaneous with meals.
19. Prednisone 20 mg Tablet Sig: As below. Tablet PO once a day
for 4 days: Please take two tablets on Friday (40 mg total), one
and a half tablets on Saturday (30 mg total), one tablet on
Sunday, and half a tablet next Monday. You should restart your
5 mg tablet as usual after that.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 511**] Home Therapy
Discharge Diagnosis:
1. Cholangitis
2. Biliary stricture
3. Biliary sepsis from obstruction
4. Headache
5. ARF
6. s/p OLT
7. Post-transplant diabetes
8. Atrial fibrillation
9. Hypothyroidism
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications as directed.
.
Please follow up with appointments as listed below.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet.
.
Please contact your health care provider or come the emergency
room if you develop high fever, shaking chills, night sweats,
worsening headache, or abdominal pain.
.
Do not take your digoxin, hydralazine, imdur, or furosemide
until you see Dr. [**Last Name (STitle) 497**] and your blood pressure is found to be
stable. **
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2116-5-6**] 10:40
Provider: [**Name Initial (NameIs) **] SUITE GI ROOMS Date/Time:[**2116-5-12**] 2:00
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1982**], MD Phone:[**Telephone/Fax (1) 1983**]
Date/Time:[**2116-5-12**] 2:00
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(1) 7619**]
|
[
"78552",
"5849",
"99592",
"42731",
"2449",
"4019",
"4240",
"25000"
] |
Admission Date: [**2166-10-6**] Discharge Date: [**2166-10-16**]
Date of Birth: [**2100-6-16**] Sex: M
Service: CT [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old
male from Bermuda who experienced substernal chest pain with
exertion since [**Month (only) 205**] of this year. An echocardiogram showed
posterior hypokinesis. A cardiac catheterization showed an
left anterior descending artery with 90% occlusion, a
posterior circumflex coronary artery with 90% occlusion, a
right coronary artery with 100% occlusion, unstable angina
and coronary artery disease.
The patient was taken by Dr. [**Last Name (STitle) 70**] to the operating room
for coronary artery bypass graft times three on [**2166-10-6**]
with a left internal mammary artery graft to the left
anterior descending artery, a saphenous vein graft to the
diagonal artery and a saphenous vein graft to the obtuse
marginal artery.
PAST MEDICAL HISTORY: The past medical history was
significant for hypertension and left hip fracture.
MEDICATIONS ON ADMISSION: Home medications included aspirin
and Lipitor.
HOSPITAL COURSE: Postoperatively, the patient did well. The
chest tube and drips were weaned off. However, the patient
did develop rapid atrial fibrillation on postoperative day #2
and was started on amiodarone. That led to an increased
liver function tests, however, and the patient was switched
to procainamide.
On postoperative day #8, the patient underwent angioplasty of
the left circumflex vessel because it was not able to be
vascularized during the procedure. He tolerated that well
and was started on Plavix by the cardiology service.
CONDITION ON DISCHARGE: The patient is being discharged on
[**2166-10-16**]. Upon discharge, his condition is stable and in
sinus rhythm. The chest is clear. The incision is clean,
dry and intact with no drainage and no pus. The sternum is
stable.
DISCHARGE MEDICATIONS:
Procainamide 750 mg and 500 mg alternating doses p.o. q.i.d.
Plavix 75 mg p.o. q.d.
Lasix 20 mg p.o. q.d. times five days.
[**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. b.i.d. times five days.
Lipitor 20 mg p.o. q.d.
Lopressor 12.5 mg p.o. b.i.d.
Percocet p.r.n.
FOLLOWUP: The patient is to follow up with his primary care
physician and cardiologist in Bermuda. He has been advised
to come back for follow up with Dr. [**Last Name (STitle) 70**] in three to
four weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 186**]
MEDQUIST36
D: [**2166-10-16**] 12:40
T: [**2166-10-16**] 12:50
JOB#: [**Job Number 35986**]
|
[
"41401",
"9971",
"42731",
"2720"
] |
Admission Date: [**2192-1-3**] Discharge Date: [**2191-5-5**]
Date of Birth: [**2192-1-3**] Sex: F
Service: NEONATOLOGY
THIS IS AN INTERIM DICTATION. PLEASE SEE PREVIOUS DISCHARGE
SUMMARIES FOR FURTHER DETAILS. THIS DICTATION SUMMARIZES THE
COURSE FROM [**3-21**] THROUGH [**5-5**].
HOSPITAL COURSE:
1. Cardiovascular: The patient remained stable without any
issues.
2. Respiratory: The patient transitioned from CPAP to nasal
cannula high flow on day of life 92. She remained on
high-flow nasal cannula for an additional ten days and then
transitioned to low flow. She currently remains on 50 cc
nasal cannula continuous flow. She will be discharged on
this. She will also have an oximeter with her at home. The
parents have been instructed to keep the oximeter on while
the baby is asleep. The alarm limits have been set 92-100%
saturation; however we would like to maintain saturations 94%
or greater.
Oxygen and O2 sat monitor supplier: [**Hospital 6549**] Medical.
Dr. [**First Name8 (NamePattern2) 4468**] [**Last Name (NamePattern1) 916**] from pulmonary at [**Hospital3 1810**] has
consulted and met the patient. He agrees with the current
management and will see her in follow up on [**2191-5-24**] in the
Pulmonary Clinic, ph. [**Telephone/Fax (1) 36136**]. Of note, an arterial
blood gas was sent on this patient and was 7.38/50/127 on 50
cc nasal cannula. A baseline chest x-ray was obtained on the
day prior to discharge which showed some moderate lung
changes consistent with bronchopulmonary dysplasia.
3. GI: The patient has been tolerating her enteral feeds.
She does have occasional spits with medicine. She has been
started on Reglan and Zantac for reflux.
4. Fluids, electrolytes and nutrition: The patient was
initially on very high-calorie formula and we decreased her
caloric density to 26 calories per ounce, however on this
amount of calories she demonstrated poor weight gain so on
[**2191-4-26**] she was transitioned back to NeoSure 30 kilocalories
per ounce, and demonstrated adequate weight gain. More
recently she has been changed to NeoSure 27 calories and
still shows adequate weight gain on this formula. The NeoSure
is concentrated to 24 calories per ounce, and then corn oil
is added to provide the additional 3 calories per ounce. A
set of electrolytes was sent on the day prior to discharge
and were within normal limits. Her potassium on those
electrolytes was 4.9. She remains on potassium replacement
since she is on Diuril but also is on Aldactone.
Discharge weight 3895 gms, L 53 cm, HC 36.5 cm.
5. Hematology: The patient remains on iron sulfate.
6. Infectious disease: No further issues.
7. Neurological: No additional issues.
8. Ophthalmology: The patient had an ophthalmologic
examination on [**2191-4-27**] which showed a mature retinas and
resolution of the stage I ROP she had had previously. She
will follow up with Dr. [**Name (NI) **] at [**Hospital3 1810**]
([**Telephone/Fax (1) 36249**]) when she is eight months old.
9. Hearing screen: The hearing screen was passed on [**4-13**].
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: To home.
PRIMARY PEDIATRICIAN: [**Hospital3 47352**], phone
#[**Telephone/Fax (1) 47353**].
CARE AND RECOMMENDATIONS:
A. Feeds at discharge: NeoSure 27, NeoSure concentrated to
24 kilocalories with an additional 3 kilocalories per ounce
of corn oil.
B. Medications:
1. Aldactone 8 mg p.o. q. day
2. Diuril 77 mg p.o. b.i.d.
3. Ferrous sulfate (25 mg per cc concentration), 0.3 cc
p.o. q.day,
4. Reglan 0.2 mg q. 8 hours
5. Zantac 8 mg p.o. q. 8 hours
6. KCL supplements 4 mEq p.o. q. 12 hours.
C. State newborn screening samples sent per protocol with no
current abnormal results.
D. Immunizations received: The patient is up to date for her
four-month immunizations including Synagis [**2191-5-4**].
E. Immunizations recommended: Synagis RSV prophylaxis should
be considered from [**Month (only) 359**] through [**Month (only) 547**] for infants who meet
any of the following three criteria: Born at less than 32
weeks; born between 32 and 35 weeks with plans for day care
during RSV season with a smoker in the household or preschool
siblings; or with chronic lung disease. Influenza
immunization should be considered annually in the fall for
preterm infants with chronic lung disease when they reach six
months of age. Before this age the family and other
caregivers should be considered for immunization against
influenza to protect the infant. The patient did receive
Synagis on [**2191-5-4**].
FOLLOW-UP APPOINTMENT:
1. The patient will follow up with [**Hospital3 47352**] on
[**Last Name (LF) 2974**], [**5-6**] at 10 AM.
2. Ophthalmology at [**Hospital3 1810**], Dr. [**Name (NI) **]
([**Telephone/Fax (1) 36249**]), when she reaches eight months.
3. Dr. [**First Name4 (NamePattern1) 4468**] [**Last Name (NamePattern1) 37305**] ([**Telephone/Fax (1) 36136**]), mother has the phone
number to call for the time of the appointment on [**2191-5-24**].
4. [**Holiday **] seals Early Intervention Program. Ph.[**0-0-**].
5. [**Hospital6 486**]. Ph. 1-[**Telephone/Fax (1) 43855**].
DISCHARGE DIAGNOSES:
1. Prematurity.
2. Respiratory distress syndrome.
3. Chronic lung disease.
4. Anemia of prematurity.
5. Rule out sepsis.
6. Feeding immaturity.
7. Apnea and bradycardia of prematurity.
8. ROP resolved.
9. Oxygen dependency.
10. Gastroesophageal reflux disease.
[**First Name8 (NamePattern2) 36400**] [**Name8 (MD) **], M.D. [**MD Number(1) 37201**]
Dictated By:[**Last Name (NamePattern1) 44694**]
MEDQUIST36
D: [**2191-5-5**] 06:56
T: [**2191-5-5**] 07:09
JOB#: [**Job Number 47354**]
|
[
"7742",
"2767"
] |
Admission Date: [**2191-9-20**] Discharge Date: [**2191-9-24**]
Date of Birth: [**2108-6-1**] Sex: F
Service: MEDICINE
Allergies:
Bacitracin
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
malaise, SOB x3-4 days
Major Surgical or Invasive Procedure:
none
History of Present Illness:
83 year old female with IPF on 2-3L NC home O2, DM2, depression,
h/o CVA 5 years prior presenting with progressive malaise x [**3-17**]
days, increased DOE, and shortness of breath referred from PCP
[**Last Name (NamePattern4) **]. [**First Name (STitle) **] for increased oxygen requirement and ? PNA. Patient
reports increased malaise over weekend with mild cough
productive of white sputum. Daughter had also noticed increased
DOE after approx. 1 min of walking as opposed to 3 minutes. She
also repors chest congestion but denies chest pain,
palpitations, fever, chills, decreased PO intake, N/V/D, leg
pain or swelling. O2 sats have been stable around 95% on 3L NC.
She made appointment with PCP and was seen in clinic where she
was noted to be 85% on 5L NC with rhonchi heard on right.
.
In the ED, initial vs were: T98.6 BP127/73 HR110 RR22 94% 3L.
CXR was difficult to interpret but revealed possible lingular
infiltrate so she was given CTX and Azithro. Blood cx x 2 drawn
prior to abx. Labs remarkable for lactate 2.2, WBC 7. She
desaturated to 78% on 3L so placed on NRB. She was weaned down
to 6L so initially was going to floor but had repeat episode of
desaturation so placed on NRB and bed request changed to ICU
given O2 requirement. VS prior to transfer: HR 100-120 BP 130/80
94% 6L NC.
.
On the floor, breathing mildly improved with O2 and pt anxious
but not coughing.
Past Medical History:
# Diabetes Mellitus
# Pontine Stroke in [**2186**] - reportedly had carotid duplex exams
at that time and no intervention recommended. She recoverd
nearly completely, though has residual mild left hemiparesis.
# Depression - she developed profound depression following her
stroke, now treated
# Hypercholesterolemia
# Hypertension
# Pulmonary Fibrosis - Followed by Dr. [**Last Name (STitle) 575**], established
care in [**2191-7-14**]. Presumed IPF although no biopsy performed.
[**Last Name (un) **] n any medicatiosn other than O2. Largely asymptomatic with
routine daily activities, but dyspnea develops with increased
exertion. Pulmonary function tests [**7-/2191**] show FEV1 and vital
capacity 0.88 and 1.0 (44 and 35% predicted respectively).
Vital capacity may be underestimated due to abrupt termination
of exhalation. Pulmonary function tests done at [**Hospital3 **] on [**2191-7-21**] show that she was not able to perform
lung volumes or diffusing capacity. Her spirometry showed FEV1
of 0.96 and vital capacity 1.1. There was no improvement after
albuterol.
Social History:
She lives in [**Hospital1 392**] with her daughter [**Name (NI) **]. She has been a
widow since [**2159**]. She worked as an appraiser for the IRS until
age 78, a job she really enjoyed. She retired at the time of her
stroke. She has two daughters, one, [**Name (NI) **], who accompanies her
lives in [**State 350**], and another who lives in [**State 5887**].
She has a son who lives in [**Name (NI) 12000**]. She smoked only for 10
years and quit many years ago. She has one alcoholic beverage
per night ([**Location (un) 21601**], scotch, or glass of wine). Denies TB
exposure. She has a dog but no other pets.
.
Family History:
No known pulmonary disease.
Physical Exam:
General: Alert, oriented, no acute distress, speaking in partial
sentences, not using accessory muscles, appears fatigued and
dyspenic with minimal movement
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
Lungs: Dry velcro crackles at bases bilateral to mid lung fields
with coarse crackles left and right mid to upper lung. No
wheezes
CV: Regular rate and rhythm, normal S1 + S2 with prominent P2,
2/6 systolic murmur LUSB
Abdomen: soft, non-tender, mildly distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
On admission:
[**2191-9-20**] 03:20PM BLOOD WBC-7.9 RBC-3.69* Hgb-10.4* Hct-31.7*
MCV-86# MCH-28.1# MCHC-32.8 RDW-17.5* Plt Ct-244
[**2191-9-20**] 03:20PM BLOOD Neuts-85.0* Lymphs-8.8* Monos-3.3 Eos-2.3
Baso-0.5
[**2191-9-20**] 03:20PM BLOOD Glucose-140* UreaN-13 Creat-0.8 Na-136
K-4.2 Cl-98 HCO3-29 AnGap-13
[**2191-9-20**] 03:20PM BLOOD Calcium-9.3 Phos-2.5* Mg-1.8
[**2191-9-20**] 03:54PM BLOOD Lactate-2.3*
On discharge:
[**2191-9-23**] 06:45AM BLOOD WBC-7.0 RBC-3.41* Hgb-9.3* Hct-30.2*
MCV-89 MCH-27.4 MCHC-30.8* RDW-17.7* Plt Ct-274
[**2191-9-23**] 06:45AM BLOOD Glucose-131* UreaN-12 Creat-0.7 Na-140
K-4.4 Cl-102 HCO3-30 AnGap-12
EKG [**2191-9-20**]
Sinus rhythm. Leftward axis. Delayed R wave progression with
late precordial QRS transition. Modest low amplitude right
precordial T wave changes. Findings are non-specific. Since the
previous tracing of [**2190-8-27**] sinus tachycardia is absent and axis
is less leftward.
Chest Xray [**2191-9-20**]
Severe pulmonary fibrosis, without new airspace opacity
definitively seen
CTA Chest [**2191-9-21**]
IMPRESSION:
1. No evidence of pulmonary embolus. Moderate-to-severe
pulmonary arterial
hypertension with evidence of right heart strain.
2. Similar appearance of extensive fibrotic disease with UIP/IPF
features.
Diffusely increased lung density cannot be adequately evaluated
with this
non-high-resolution CT technique, although could represent
pulmonary edema,
infection or acute exacerbation of fibrotic process.
3. Stable left upper lobe 6-mm nodule.
4. Large hiatal hernia.
5. Thyroid nodule, stable.
6. Compression fracture, stable.
7. Subcentimeter liver hypodensity, which is too small to
characterize,
stable.
Brief Hospital Course:
83 year old woman with pulmonary fibrosis admitted with
progresive malaise and DOE with increased O2 requirement last
3-4 days.
# Hypoxic respiratory distress: The patient was admitted to the
MICU due to her high oxygen requirement. The differential for
the patient's respiratory distress included either bacterial or
viral PNA, PE, CHF, or IPF exacerbation. She was started on a
5-day course of ceftriaxone and azithromycin to cover for CAP.
She underwent a CTA which showed no evidence of a PE. She was
initially placed on a 100% NRB, but was able to be weaned to
nasal cannula oxygen soon after reaching the MICU. She remained
stable on 5-6L NC O2, with O2 sats in the mid 90s. She did
desaturate to the mid 70s-80s with exertion, however, both her
and the family say that is her normal baseline. She would
recover to the mid 90s quickly with rest. Steroids were not
given as the patient seemed to be improving on the antibiotics
with a rapid wean off the NRB. Ms. [**Known lastname 10113**] was transferred to
the General Medicine Floor when she was stable on 6L nasal
cannula. Pulmonary evaluated her and recommended supplemental
O2 to maintain O2sats > 90%. Initiation of steroids was deferred
for now based on patient's preference and concern re: glycemic
control but could consider a steroid trial if she does not
progress as expected while at inpatient pulm rehab. Vasodilator
therapy should be considered as an outpatient once disease more
stabilized but not currently. Patient should schedule
appointment with pulmonologist Dr. [**Last Name (STitle) 575**] within 1-2 weeks of
discharge for repeat echocardiogram, spiromemtry/DLCO, +/-
imaging.
.
# DM2: The patient's metformin was held as she got a contrast
load for her CTA. She was covered with an ISS while in-house.
Metformin restarted on discharge.
.
# Hypertension: Home amlodipine was initially held in MICU, then
restarted once pressures began to increase.
.
# Hyperlipidemia: Continue home atorvastatin 10mg.
.
# History of CVA: Continued on daily aspirin.
.
# Depression and Anxiety: Continued on Lexapro, Mirtazapine and
ativan as needed.
.
# Normocytic Anemia: Nl MCV with widened RDW. [**Month (only) 116**] have element
of iron deficiency anemia given ferritin 31. Should have
further workup as an outpatient.
.
# Lung nodule: Stable 6mm left upper lobe nodule seen on CTA
chest compared to 6/[**2191**].
Medications on Admission:
Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN
Amlodipine 2.5 mg PO/NG DAILY
Aspirin 325 mg PO/NG DAILY
Azithromycin 250 mg PO/NG Q24H
Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
CeftriaXONE 1 gm IV Q24H
Escitalopram Oxalate 20 mg PO DAILY
Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **]
Heparin 5000 UNIT SC TID
Insulin SC (per Insulin Flowsheet)Sliding Scale
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN sob
Mirtazapine 15 mg PO/NG HS
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
Inhalation twice a day.
6. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO once a day.
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Other
Continuous oxygen by nasal cannula as needed to maintain O2sat
>90%
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
1. Pneumonia versus Upper Respiratory Infection
2. Interstitial Pulmonary Fibrosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted for shortness of breath and increasing oxygen
requirements. You were treated for pneumonia with antibiotics.
For several days you were in the in the intensive care unit so
that specialized pulmonologists could watch your breathing
status closely. You were transferred to the general medicine
floors when your oxygen requirements were more stable.
You will be discharged to pulmonary rehab. Please continue to
take your home medications as directed.
Followup Instructions:
Please schedule an appointment with Dr. [**Last Name (STitle) 575**] ([**Telephone/Fax (1) 612**])
in the Pulmonary Clinic within [**1-15**] week of discharge from
pulmonary rehab.
Previously scheduled appointments:
Department: PULMONARY FUNCTION LAB
When: TUESDAY [**2192-1-31**] at 11:00 AM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: TUESDAY [**2192-1-31**] at 11:00 AM
Department: MEDICAL SPECIALTIES
When: TUESDAY [**2192-1-31**] at 11:30 AM
With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"4168",
"25000",
"4019",
"2720"
] |
Admission Date: [**2123-5-31**] Discharge Date: [**2123-6-11**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 85 year old
male with the chief complaint of left lower extremity
ischemia, who presented with worsening pain times three days
in the distal left foot, which has been persistent. The
patient had some intermittent pain the day prior. The
patient had positive tingling and numbness and decreased
ability to move the foot and toes. The foot was also cool
and discolored. The patient denies any coronary artery
disease, congestive heart failure, arrhythmias, diabetes
mellitus. The patient had no known peripheral vascular
disease. He gives some history of claudication times one
year with left lower extremity pain after walking
approximately one quarter of a mile which resolved with rest.
PAST MEDICAL HISTORY:
1. Rheumatoid arthritis.
2. Hypertension.
PAST SURGICAL HISTORY:
1. Bowel resection of unknown dates.
2. Back surgery during World War II.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q. day.
2. Atenolol of unknown dose.
ALLERGIES: The patient had no known drug allergies.
SOCIAL HISTORY: The patient had a social history significant
for a 55 year smoking history.
PHYSICAL EXAMINATION: On physical examination, the patient
was afebrile; vital signs are stable. He was complaining of
pain in the left foot; in no apparent distress. Alert and
oriented times three. Lungs were clear to auscultation
bilaterally. Heart was regular rate and rhythm. Abdomen was
soft, nontender, nondistended. Extremity examination was
significant for a cool and discolored left foot, bilateral
ankle edema, left greater than right. Left lower extremity
had intact sensation but decreased motor strength, decreased
plantar and dorsiflexion of the foot and decreased to flexion
and extension. Pulse examination was significant for
palpable carotids bilaterally with no bruits, palpable
femorals bilaterally. Doppler-able popliteals bilaterally
with biphasic signals. Biphasic signal on the right dorsalis
pedis and no signal on the left dorsalis pedis. Monophasic
posterior tibial on the left and a biphasic posterior tibial
on the right. Rectal examination was heme negative; no
masses noted.
LABORATORY: On admission, white blood cell count 9.4,
hematocrit 31.6, platelets 302. Sodium 145, potassium 4.4,
chloride 105, bicarbonate 26.5, BUN 28, creatinine 0.9,
glucose 82, INR of 1.1.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
Vascular Service with Dr. [**Last Name (STitle) **] attending. Emergent
angiogram was arranged which revealed on [**2123-5-31**], marked
aortoiliac disease with severe stenosis of the proximal left
common iliac artery, occluded left superficial femoral
artery, which reconstituted above the knee and the popliteal
artery on the left which occluded just below the knee joint.
No run off vessels were present proximally, however, there
was reconstitution of a very distal left posterior tibial
artery which supplied the patent but diffusely diseased
plantar branches. Dorsalis pedis artery was occluded.
A chest x-ray on [**2123-5-31**], revealed bilateral predominantly
lower zone interstitial changes, possibly due to chronic
interstitial fibrosis but no acute cardiopulmonary
abnormalities identified.
The patient was taken to the Operating Room on [**2123-6-1**],
for femoral to femoral Dacron bypass graft and endarterectomy
of the right common femoral artery. For a more detailed
account, please see operative report. In addition,
preoperative Urology consultation was obtained which revealed
a distal urethral stricture. A Foley catheter was placed and
antibiotics were started as prophylaxis. Directly
postoperatively, the patient was noted to have no dorsalis
pedis signal in the PACU. The patient was examined and had
an open fem-fem graft but poor flow to the foot. The
decision at that time was made to observe. The left foot
remained cool and mottled with blue toes and a monophasic
posterior tibial signal.
Postoperatively, the patient went to the Vascular Intensive
Care Unit where he was on a Nitroglycerin drip for blood
pressure control.
The patient was transferred to the Floor on [**2123-6-4**]. A
chest x-ray on [**2123-6-7**], was noted to have an opacity in
the retrocardiac region suggestive of pneumonia with a
persistent bilateral interstitial pattern likely due to
congestive heart failure.
On [**2123-6-9**], the patient was taken to the Operating Room
again for a thrombectomy and revision of fem-fem Dacron
bypass graft and exploration of the left posterior tibial
artery. Intraoperatively, the patient was unstable and was
on pressors and it was decided not to persist with the
original plan for distal arterial reconstruction. The
patient went postoperatively to the Neurological SICU where
he remained intubated and sedated.
Postoperatively, the patient was made "DO NOT RESUSCITATE"
per family discussion with Dr. [**Last Name (STitle) **]. Postoperatively, the
patient required multiple fluid boluses for unstable
hemodynamics. The patient continued to be hemodynamically
unstable. On [**2123-6-10**], the patient, after discussion with
Dr. [**Last Name (STitle) **] and family, was made COMFORT MEASURES ONLY.
On [**2123-6-11**], the patient was pronounced. The time of death
was 01:20 a.m.
Cause of death: Progressively worse hypoxia, resulting in a
bradycardic arrest.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 19472**]
Dictated By:[**Name8 (MD) 7190**]
MEDQUIST36
D: [**2124-3-10**] 14:24
T: [**2124-3-10**] 14:56
JOB#: [**Job Number 49381**]
|
[
"9971",
"42731",
"4019"
] |
Admission Date: [**2184-2-21**] Discharge Date: [**2184-3-6**]
Date of Birth: [**2156-2-6**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Bleeding from Right eye
Major Surgical or Invasive Procedure:
[**2184-2-23**]: Cerebral Angiogram with coiling and sacrafice of
right Carotid artery
History of Present Illness:
This is a 28 year old female status post high speed MVA
evening of [**2184-1-14**] who is well known to the neurosurgery
service
and is status post interventional Neuroradiology Angiogram and
Coiling carotid cavernous fistula on [**2184-2-13**].This patient was
at her rehabilitation facility when at 1000 this morning a
trickle of blood came from her right eye. The patient had been
followed by opthomology as at the time of her initial injury on
[**2184-1-14**] she had multiple injuries which included right orbital
compartment syndrome and lateral canthotomy. The patient wears
a
right eye patch and has irritated, edematous conjunctiva.
Past Medical History:
Post C2 body fx, bilat preseptal hemorrhage, small bilateral
PTX, splenic injury s/p splenectomy, L squamous temporal bone
fx, bilat anterior acetabular fx, R inferior pubic ramus fx, fx
ant tibial cortex, Carotid->cav sinus fistula s/p embolization.
Annular tear C2/3 disk, Prevertebral hematoma, skull base -> C4
Social History:
Before the accident was living independently, was recently in
acute rehab prior to her readmission to Neurosurgery, + history
IVDA
Family History:
non-contributory
Physical Exam:
Upon discharge:
EO, alert and oriented x3, L pupil reactive, R gaze deficit
which has been improving, MAE with full motor, walking
independently. Tolerating PO intake without issue.
Pertinent Results:
[**2184-2-21**] 12:11PM GLUCOSE-109* UREA N-13 CREAT-0.7 SODIUM-140
POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-32 ANION GAP-15
[**2184-2-21**] 12:11PM estGFR-Using this
[**2184-2-21**] 12:11PM CALCIUM-10.8* PHOSPHATE-5.3* MAGNESIUM-2.1
[**2184-2-21**] 12:11PM WBC-9.7 RBC-4.41# HGB-13.0# HCT-40.2# MCV-91
MCH-29.5 MCHC-32.3 RDW-13.5
[**2184-2-21**] 12:11PM NEUTS-62.7 LYMPHS-21.5 MONOS-7.3 EOS-7.5*
BASOS-1.0
[**2184-2-21**] 12:11PM PLT COUNT-613*
[**2184-2-21**] 12:11PM PT-11.9 PTT-33.9 INR(PT)-1.1
CXR [**2-22**]: Pleural effusions have resolved. Free air has also
resolved. A
tracheostomy is again noted. The heart is normal in size. The
mediastinal
and hilar contours appear unchanged. The lungs appear clear. The
bony
structures are unremarkable.
IMPRESSION: No evidence of acute disease.
CT head [**2184-2-25**]
1. Status post coiling of right ICA for carotid cavernous
fistula, with
subarachnoid hemorrhage in the right sylvian fissure and the
suprasellar
cisterns.
2. Diffuse swelling/edema in the right cerebral hemisphere.
Pelvis Xray [**2184-2-28**]:
IMPRESSION: Single frontal view of the standing pelvis shows
substantial bony healing of fractures of the lesser ring of the
right pelvis. Bony fusion is not complete in the right
ischiopubic junction, and if this as a potential source of
concern, oblique views should be obtained.
Tib/Fib Xray [**2184-2-28**]:
Scanning of the anterior cortical margin of the right tibia, at
the level of a small cortical defect, shows an indication of
healing at the site of the pretibial laceration.
Cspine Xrays [**2184-3-1**]:
FINDINGS: Two lateral views of the cervical spine. No AP view
provided.
Halo device is present. Patent airway. Tracheostomy present.
Normal
prevertebral soft tissues. Prior C2-C3 ACDF with anterior
instrumentation and intervertebral disc spacer. The hardware is
unchanged in position. No change in alignment. The known C2
periprosthetic frature is not seen on these radiographs.
IMPRESSION: No change from the most recent radiographs.
Brief Hospital Course:
Ms. [**Known lastname 1968**] presented to the ED on [**2-21**] from rehab and
neurosurgery was consulted for c/o bleeding from right eye. She
has no neurological complaints at that time. She was admitted to
the step down unit for q 2hr neuro checks. Optho was consulted
and on examination she was noted to have elevated occular
pressure to 28. Per their recommendation she was started on
additional eye drops, Dorzolamide 2%/lacrilube TID, for the
bleeding from her cracked conjuntiva.
On [**2-22**] she was pre-oped for a cerebral angiogram on monday and
was cleared for transfer to the floor with tele. On [**2-23**] she
underwent the cerebral angiogram angio with coil and sacrafice
of right carotid. Both groin sites had angioseal. She was
transfered to the ICU on [**2-25**] with headache, nausea and CT
showed some SAH. Decadron was started for headaches and some
cerebral edema. She was seen by opthomology again on [**2-26**] and
she needs to follow up with oculoplastics. OMFS recommedned a
soft diet and mouth exercises. Outpatient follow up was made.
Orthopedic surgery was consulted in the hospital for follow up
of her tib/fib fractures and pelvic injury. Images were ordered
and reviewed by their team and the timing of follow up was
confirmed for 8 weeks in clinic with Dr. [**Last Name (STitle) 1005**].
The trach was removed on [**2184-3-5**] at bedside. PEG remained in
place with plans for removal with Dr [**Last Name (STitle) **].
A family meeting was held on [**2184-3-5**] in which discharge planning
was discussed, some major points:
- Follow-up / signs to look for were discussed
- Patient teaching on SAH and normal course of recovery
- Cognitive therapy resources were pointed out
- Pain management and Methadone taper:
- [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 90747**] manages opioid withdrawl, weaning
Methadone, but can not be on Vivitrol until off dilaudid. She
can be contact[**Name (NI) **] at [**Telephone/Fax (1) 90748**] (o), [**Telephone/Fax (1) 90749**] (c).
- In collaboration with [**Location (un) **], Neurosurgery will supply
methadone taper to off over the next few days. We will also
provide narcotic Rx for 7 days. At this point, the patient will
discuss her readiness to stop Dilaudid for pain and use
non-opoid forms of pain management so she may restart her
Vivitrol. Neurosurgery will provide a refill at that time if
patient feels she is not ready but our main goal would be to
provide a Rx for a non-opoid medication that will be accepted by
the protocol [**First Name8 (NamePattern2) **] [**Location (un) **] can restart the Vivitrol.
- [**Hospital **] rehab was offered but declined
- Patient and family agreed on plan to discharge home on
Saturday 12 noon.
- VNA will make a couple of home visits to follow-up and provide
additional support.
- Halo is not removed in the OR under general
- Trach will be removed.
She was discharged home on [**2184-3-6**].
Medications on Admission:
artificial tears, asa 325, plavix 150, baci/poly eye [**Doctor Last Name **] tid,
colace, pepcid, methedone 7.5 [**Hospital1 **], senna, timolo 1 drop [**Hospital1 **] to r
eye
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**2-2**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
Disp:*QS QS* Refills:*2*
5. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. bacitracin-polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic Q8H (every 8 hours).
Disp:*QS QS* Refills:*2*
7. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic Q 8H (Every 8 Hours).
Disp:*QS QS* Refills:*2*
8. benzocaine (pectin-carboxymcl) 20 % Paste Sig: One (1) Appl
Mucous membrane QID (4 times a day) as needed for tooth pain.
Disp:*QS QS* Refills:*0*
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
10. dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
Disp:*QS QS* Refills:*2*
11. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for anxiety.
Disp:*30 Tablet(s)* Refills:*0*
12. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day)
for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
14. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): Continue while on steroids.
Disp:*60 Tablet(s)* Refills:*0*
15. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**5-7**]
hours as needed for pain: 7 day supply.
Disp:*42 Tablet(s)* Refills:*0*
16. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours: 2mg (1 tab) every 12hrs for 4 doses then 1mg
(0.5 tab) every 12hrs for 2 doses then 1mg (0.5 tab) once a day
for one dose, then discontinue.
Disp:*QS Tablet(s)* Refills:*0*
17. promethazine 12.5 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Steward Home Care
Discharge Diagnosis:
Carotid Cavernous Fistula
Subarachnoid hemorrhage
Cerebral edema
Post C2 body fx w/ C2-3 flex-distraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily.
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? No driving until you are no longer taking pain medications
*** Because of your cervical fractures/ Halo- no heavy lifting,
10 lb weigh restriction. ****
* Neurosurgery will continue to provide you pain medications
until you begin your outpatient medication protocol as discussed
at our family meeting.
* Follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 90747**] regarding your weaning
process/ beginning outpatient protocol. In collaboration with
[**Location (un) **], we have decided to wean your Methadone to 2.5mg twice
daily for a few more days then discontinue. At that time, please
evaluate your level of pain/ comfort- if you are able to stop
Dilaudid then [**Location (un) **] can work with you on restarting your Vivitrol
and help with non-opoid pain manangement. As long as you are on
opoids, you cannot restart Vivitrol. [**Location (un) **] can make
recommendations to you and Neurosurgery on what pain medications
are allowed with the protocol.
* Neurosurgery may decline to write for narcotic prescriptions
if the following happens: Multiple providers supplying pain
medications without Neurosurgery knowing, suspected abuse or
mis-use of the pain medications, and not using the medication as
specefically prescribed.
* Neurosurgery will not provide replacement pain medications if
pills are stolen or lost.
* Neurosurgery may ask for urine analysis to confirm proper use
of medication or rule out use of illicit medications if abuse or
mis-use is suspected.
Decadron (Dexamethasone- steroid) Taper:
2mg (1 tab) every 12hrs for 4 doses then
1mg (0.5 tab) every 12hrs for 2 doses then
1mg (0.5 tab) once a day for one dose, then discontinue.
Team Contact [**Name (NI) **]:
Neurosurgery Dr [**First Name (STitle) **] [**Telephone/Fax (1) 4296**]
Spine Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 3736**]
Trauma Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 600**]
Eye Oculoplastics [**Telephone/Fax (1) 88077**]
Facial fractures Dr [**Last Name (STitle) 54446**] [**Telephone/Fax (1) 68463**]
Followup Instructions:
Neurosurgery Follow-up:
* Please follow-up with Dr [**First Name (STitle) **] in 4 weeks for follow-up with
a MRA of the brain. At that time we can discuss whether a
follow-up angiogram is needed. Please call [**Telephone/Fax (1) 4296**] to make
this appointment or call with any questions.
OMFS (facial fractures):
* F/u with Dr. [**Last Name (STitle) 54446**] on [**2184-3-12**] at 10am at [**Hospital 40530**] clinic at
[**Hospital6 **]. They are located at [**Last Name (NamePattern1) **],
[**Hospital 30433**]
[**Hospital **] Care Center, [**Location (un) 442**]. Please call [**Telephone/Fax (1) 68463**] with
any questions or concerns.
**They have recommended that you see your general dentist to
address decayed unrestorable teeth.
Opthamology (Eye):
*You will need to be seen at [**Hospital 13128**] with with
occulplastics. The phone number to make this appointment is
[**Telephone/Fax (1) 88077**].
Trauma Service (Feeding tube/splenectomy)
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2184-2-17**] at 2:00 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST
You will need a chest x-ray prior to this appointment. Please go
to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **]
Radiology 30 minutes prior to your appointment. Please arrive
there at 1:30pm.
Orthopedics (fractures, NOT SPINE)
Department: ORTHOPEDICS
When: [**2184-4-20**] at 9:20 AM (Xrays before)
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS - Xrays
When: [**2184-4-20**] at 09:10 AM
Where: [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Spine (Halo):
You will need to follow up with Dr. [**Last Name (STitle) 1352**] in 2 weeks for care
of your halo. Please call for appointment. Tje office was
notified to set this appointment up with you in the next few
days.
|
[
"2859"
] |
Admission Date: [**2141-1-19**] Discharge Date: [**2141-2-13**]
Date of Birth: [**2062-9-9**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
[**2141-1-19**]:
Esophagogastroduodenoscopy with epinephrine injection and
clipping at bleeding duodenal ulcer.
[**2141-1-19**]:
Angiographic coil embolization of gastroduodenal artery.
[**2141-1-24**]:
Exploratory laparotomy, lysis of adhesions, antrectomy, subtotal
cholecystectomy, choledochocholedochostomy.
History of Present Illness:
Pt is a 78M well known to this service having undergone an
ex-lap, sigmoid colectomy, end colostomy & [**Doctor Last Name 3379**] procedure
on [**2140-12-25**] for perforated diverticulitis and associated sepsis.
His hospital course included a week-long ICU course for
hypotension, respiratory failure, renal failure. His organ
failure resolved and he was ultimately discharged from the floor
to rehab on POD 11 tolerating regular food with NJ TF and ostomy
output. Cr was back at baseline (2.2).
Had been doing reasonably well at rehab. However, on [**2141-1-12**]
HCT 25.2 from 32 on [**2141-1-9**]. Guaiac +, tranfused 2U PRBCs, INR
2.34 on coumadin 2, Cr 2.6 (from 1.32 on [**2141-1-9**]). Started
colchicine for joint pain.
[**2141-1-13**] HCT 29. No gross bleeding. Started prednisome 30 on
[**1-14**] for gout flare unresponsive to colchicine. [**1-16**] Cr fond
to be 3.52 from 2.86. Colchicine & lasix were stopped. He was
started on IVF.
Developed BRB from his colostomy on [**2141-1-17**]. INR was 1.9 at
the time (on coumadin for afib). He was given 2U FFP, vit K IV,
and 2U PRBCs. EGD on [**2141-1-18**] at [**Hospital1 **]: mild gastritis,
duodenal ulcer with deep crater (5cm) with bleeding vessel.
Injected with Epi (3cc) and bipolar cautery perofrmed. Bx were
taken for H Pylori. He was started on a protonix gtt &
octreotide gtt along with carafate. Prednisone was stopped.
Transferred to [**Hospital1 18**] today for further care. Pt has abdominal
"discomfort". No N/V. + Melena. Has been hemodynamically
stable.
Past Medical History:
PMH: St. [**Male First Name (un) 1525**] pacemaker, atrial fibrillation, sick sinus
syndrome, aortic stenosis, CHF, EF 45-50%, CRI, gout, HTN
PSH: B knee replacements, [**Doctor Last Name 3379**] Procedure [**2140-12-25**] for
perforated diverticulitis with sepsis
Social History:
Married
Retired electrician
Former smoker, social drinker, no rec drugs
Family History:
Father died at 61 from lung CA
mother died at 93 from "old age"
Physical Exam:
afebrile 87 128/45 18 95%2L
NAD, AO
No jaundice or icterus
CTA B/L
RRR
Abd soft, NT, ND, protuberant. Midline incision with good
granulation tissue. Ostomy bag full of dark, thin melana
No LE edema
Pertinent Results:
[**2141-1-19**] 03:44PM WBC-12.7* RBC-3.02* HGB-9.4* HCT-28.2* MCV-93
MCH-31.0 MCHC-33.3 RDW-16.3*
[**2141-1-19**] 03:44PM PLT COUNT-315
[**2141-1-19**] 03:44PM PT-20.8* PTT-31.9 INR(PT)-1.9*
EGD [**2141-1-19**]:
A single crate, oozing, 2X5 cm ulcer was found in the
post-duodenal bulb. The ulcer was clearly demarcated and has
gritty base that cound not hold the endoclip. Active bleeding
was seen through the base of ulcer. During the procedure,
approximately 100 cc blood lost. however, pt is hemodynamic
stable. 4 1 cc.Epinephrine 1/[**Numeric Identifier 961**] injections were applied for
hemostasis with partial success. Three endoclips were
unsuccessfully applied to the the ulcer at post-duodenal bulb
for the purpose of hemostasis.
IR coil embolization [**2141-1-19**]:
Successful and uncomplicated prophylactic gastroduodenal artery
embolization for bleeding duodenal ulcer (as seen on endoscopy)
using a Hilal coils ranging from 3 mm x 3 cm, 4 mm x 4 cm and 6
mm x 6 cm (total of eight coils).
CT abdomen/pelvis [**2141-2-1**]:
There is small-to-moderate amount of ascites. A JP drain is
noted in the right abdomen. There is extensive mesenteric fat
stranding and edema, without evidence of large fluid collections
or abscess formation. The gastrojejunostomy site is visualized;
however, its patency cannot be assessed due to lack of contrast.
The oral contrast given through J-tube is visualized throughout
small and large bowel and within the colostomy bag, there is no
evidence of an obstruction. No extraluminal contrast.
CT abdomen/pelvis [**2141-2-9**]:
The patient is with Roux-en-Y bypass. There is normal
opacification of the stomach and the jejunostomy, without
evidence for active leak. There is no evidence of bowel
obstruction. A surgical drain is seen in the right upper abdomen
terminating in the sub-diaphragmatic region. There is diffuse
mesenteric fat stranding and moderate amount of simple ascites
seen throughout the abdomen and pelvis, stable since the prior
study. No focal fluid collections or abscesses are detected.
There is no intra-abdominal free air. Subcutaneous air at the
level of the incision site likely relates to the recent
procedure.
Brief Hospital Course:
[**1-19**]: Admitted to SICU, underwent EGD and IR embolization of
GDA, transfused 5u PRBC.
[**1-20**]: Hct stable - no transfusions since IR. Remained
intubated.
[**1-21**]: Extubation not attempted as pt noted to be having copious
secretions. TFs started.
[**1-22**]: Extubated. Lasix 60mg IV x 1.
[**1-24**]: To OR for exploratory laparotomy, antrectomy, roux-en-Y
gastroJ, feeding jejunostomy, subtotal chole and anastamosis of
transected CBD. Intubated post-op. Bronched for L lung
collapse and desaturations. JP drain to RUQ.
[**1-26**]: Repeat ECHO. Cc:cc repletions d/c'd and IVF rate
decreased. Standing albumin started w/ subsequent successful
weaning of pressor requirement.
[**1-29**]: TF increased ([**2-5**] to 3/4 strength). Negative fluid
balance secondary to JP output draining bilious succus, likely
from duodenal stump leak.
[**2-5**]: JP drainage sent for bili (7.9) and amylase (61,700).
[**2-6**]: Adjusted TF.
[**2-7**]: Transferred to floor.
[**2-9**]: Pt readmitted to SICU for mental status changes. NGT
placed by primary team. CT abdomen/pelvis.
[**2-10**]: Given 1 FFP in preparation for PTC placement, unable to get
done in IR, postponed to [**2-11**]. Getting albumin boluses for low
uop.
[**2-11**]: Given 2U FFP prior to PTC placement and 3U FFP during
procedure. Patient was intubated in IR. They were unable to
place drain in bile ducts. Received 2U PRBC. Kept intubated
post-procedure on propofol and neo. Oliguric with metabolic
acidosis with lactate of 6.5. Started on bicarb gtt and
refeeding JP output through J-tube.
[**2-12**]: Hypotensive, requiring second pressor. Anuric with FeNa 6%
suggesting ATN. Failed [**Last Name (un) 104**] stim test suggesting functional
adrenal insufficiency.
[**2-13**]: Hypotensive, requiring third pressor. Family meeting was
held and patient rendered CMO. Expired.
Medications on Admission:
1. sucralfate 1gm PGT [**Hospital1 **]
2. lasix 20mg PGT daily
3. octreotide 25 mcg gtt
4. promod 30cc PGT q8hr
5. insulin sliding scale
6. ascorbic acid 500mg PGT daily
7. MVI 5mg PGT daily
8. saccharomyces 250mg PGT q12
9. simvastatin 20mg PGT qhs
10. atenolol 12.5 PO daily
11. tylenol prn
12. Coumadin -- held
13. Prednisone 30mg 12/11-15/[**2140**]
14. Jevity 1.2 90ml cycled from 6pm to 7am
Discharge Medications:
None.
Discharge Disposition:
Expired
Discharge Diagnosis:
Death.
Discharge Condition:
Expired.
Discharge Instructions:
He who has gone, so we but cherish his memory.
Followup Instructions:
None.
Completed by:[**2141-2-13**]
|
[
"0389",
"5845",
"51881",
"99592",
"5180",
"2762",
"4280",
"40390",
"5859",
"4241",
"42731"
] |
Unit No: [**Numeric Identifier 60304**]
Admission Date: [**2157-2-4**]
Discharge Date: [**2157-2-7**]
Date of Birth: [**2157-2-4**]
Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: The patient is a 2045 gm product
of a 34 [**4-9**] week gestation born to a 33 year old gravida 7,
para 2 woman, born after pregnancy complicated by maternal
gestational diabetes. Mother was admitted in preterm labor
the day of delivery. Prenatal screens notable for A
positive, antibody negative, hepatitis B surface antigen
negative, RPR nonreactive, Rubella immune and Group B
Streptococcus unknown. The infant was delivered by cesarean
section. At delivery the patient emerged vigorous. Apgars
were 7 at one minute and 8 at five minutes. The infant was
given blow-by oxygen and stimulation and brought to the
Neonatal Intensive Care Unit after visiting with parents.
PHYSICAL EXAMINATION ON ADMISSION: Birthweight 2045 gm, 25th
percentile, length 44 cm, 25th percentile, head circumference
31, greater than 25th percentile. On examination, pink,
active, nondysmorphic infant, well saturated and perfused, no
skin lesions. Head, eyes, ears, nose and throat within
normal limits. Normal S1 and S2, without murmurs. Abdomen
benign. Lungs clear, comfortable. Genitalia, normal female.
Neurologic, nonfocal and age appropriate.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: Respiratory - The
infant has remained on room air throughout this
hospitalization with oxygen saturations greater than 95
percent. Respiratory rate, 30s to 60s. The infant has not
had any apnea or bradycardia this hospitalization.
Cardiovascular - Infant has remained hemodynamically stable
this hospitalization, no murmur. Heart rate is 130s to 140s.
Fluids, electrolytes and nutrition - The infant was initially
receiving nothing by mouth, 80 cc/kg/day of D10/W. Enteral
feedings were started on day of life Number 1 and the infant
is currently taking over a minimum of 80 cc/kg/day of Similac
20 cal/oz p.o. The current weight is [**2111**] grams. Most
recent electrolytes on day of life Number 2 showed a sodium
of 147, potassium 4.5, chloride 109, bicarbonate 50.
Gastrointestinal - The infant has not received phototherapy,
the most recent bilirubin was on [**2-6**], it was 9.4 with
direct of 0.3.
Hematology - Complete blood count on admission revealed white
blood cell count 10.8, hematocrit 57.2 percent, platelets
306,000, 36 neutrophils, 0 bands, 51 lymphocytes.
Infectious disease - The infant received 48 hours of
Ampicillin and Gentamicin. Blood cultures were negative at
48 hours and antibiotics were discontinued. Blood culture
remains negative to date.
Neurology - Normal neurologic examination.
Sensory - Hearing screening is recommended prior to
discharge.
Psychosocial - Parents involved.
CONDITION ON DISCHARGE: Stable on room air.
DISCHARGE DISPOSITION: To Level 1 Newborn Nursery.
PRIMARY PEDIATRICIAN: Dr. [**Last Name (STitle) 60305**] in [**Location (un) 1456**].
CARE/RECOMMENDATIONS: Feedings at discharge - Similac 20
cal/oz minimum 80 cc/kg/day.
Medications - None.
Car seat position screening - Recommended prior to discharge
home.
State newborn screen - Will be sent on day of life Number 3.
Immunizations - Hepatitis B vaccine recommended prior to
discharge home.
Immunizations recommended - Synagis respiratory syncytial
virus prophylaxis should be considered from [**Month (only) **] through
[**Month (only) 958**] for infants who meet any of the following three
criteria: 1. Born at less than 32 weeks; 2. Born between 32
and 35 weeks with two of the following, daycare during
respiratory syncytial virus season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school age siblings; or 3. With chronic lung disease.
Influenza Immunizations recommended annually in the fall for
all infants once they reach six months of age, before this
age and for the first 24 months of the child's life,
immunization against influenza is recommended for household
contacts and out of home caregivers.
Follow up appointments - Recommended with primary
pediatrician.
DISCHARGE DIAGNOSIS: Prematurity.
Rule out sepsis, ruled out.
Indirect hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 48738**], MD [**MD Number(2) 55708**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2157-2-7**] 13:42:23
T: [**2157-2-7**] 17:17:33
Job#: [**Job Number 56091**]
|
[
"V053",
"V290"
] |
Admission Date: [**2155-3-14**] Discharge Date: [**2155-3-19**]
Date of Birth: [**2132-1-9**] Sex: M
Service: Medical ICU and [**Doctor Last Name **]
CHIEF COMPLAINT: Nausea, vomiting, and hyperglycemia.
HISTORY OF PRESENT ILLNESS: Patient is a 23-year-old man
with a history of type 1 diabetes complicated by retinopathy,
neuropathy, and nephropathy, hypertension, migraine
headaches, and congestive heart failure with an ejection
fraction of 35% who presents with three days of nausea,
vomiting, and hyperglycemia. The patient also reported
diarrhea five times on the day of admission with severe
refractory vomiting approximately 10-15x/day. He reports in
addition to that, chills and abdominal pains, but denies any
fever, chest discomfort, or shortness of breath. He did have
a sick contact in his mother who had similar diarrheal
symptoms recently. Denies any bright red blood per rectum or
any melena.
Upon presentation to the Emergency Department, he had one
episode of coffee-ground emesis. Nasogastric lavage at the
time cleared after 1 liter of normal saline. He was volume
resuscitated with 2 liters of normal saline, started on an
insulin drip for his elevated blood glucose, and was brought
up into the Medical Intensive Care Unit for further
management.
PAST MEDICAL HISTORY:
1. Type 1 diabetes with triopathy.
2. Chronic renal insufficiency secondary to diabetic
nephropathy.
3. Hypertension.
4. Left Charcot foot.
5. Migraine headaches.
6. Depression.
7. Congestive heart failure with ejection fraction of 35% and
global left ventricular hypokinesis.
ALLERGIES: Zestril leads to lightheadedness.
MEDICATIONS ON ADMISSION:
1. Lasix 80 mg po bid.
2. Lantus insulin 20 units q am.
3. Humalog sliding scale.
4. Norvasc 10 mg q day.
5. Labetalol 600 mg [**Hospital1 **].
6. PhosLo 667 mg [**Hospital1 **].
7. Epo 5,000 units 2x/week.
8. Hydralazine 25 mg qid.
9. Isordil 20 mg tid.
SOCIAL HISTORY: The patient smokes approximately one pack of
cigarettes per day. He is poorly compliant with his diabetic
care. He gives a history of both alcohol and marijuana
usage.
FAMILY HISTORY: Significant for diabetes. He has two
sisters also with the disease.
PHYSICAL EXAMINATION ON ADMISSION: Temperature is 97.1,
heart rate 88, blood pressure 155/70, respiratory rate 20,
and O2 saturation is 99% on room air. In general, he
appeared in no acute distress. Pertinent physical findings
reveal that his sclerae were anicteric. He is status post
right vitrectomy. His neck was supple. His heart was
tachycardic with a 3/6 systolic ejection murmur at the right
upper sternal border and a [**3-6**] murmur at the apex. His lungs
were clear to auscultation bilaterally. His abdominal
examination revealed normoactive bowel sounds, soft,
nontender, nondistended, he had guaiac negative stool on
rectal examination. Extremities were without clubbing,
cyanosis, or edema. Neurologic examination was nonfocal.
Examination of his skin revealed no rashes.
LABORATORIES ON EXAMINATION: Sodium was 121, potassium 6.7,
chloride 84, bicarb 8, BUN and creatinine of 111 and 8.1
respectively. Blood glucose initially on admission was
1,111. His anion gap was 29. Complete blood count revealed
a white blood cell count of 10.8, hematocrit of 29.9,
platelets of 427. He had no bands on his differential.
Coags were within normal limits. LFTs revealed an ALT of 62,
AST of 56, alkaline phosphatase of 301, amylase of 63, total
bilirubin of 0.4. Initial arterial blood gas was 7.20/23/89.
Electrocardiogram was sinus rhythm at 95 beats per minute
with a normal axis.
Chest x-ray revealed small bilateral effusions.
HOSPITAL COURSE:
1. Diabetic ketoacidosis: The patient was admitted to the
Intensive Care Unit for management of his diabetic
ketoacidosis. He was treated aggressively with insulin drip,
aggressive volume resuscitation, and electrolyte management,
and by the third hospital day, was off of insulin drip and
back on lantus and Humalog sliding scales. His diabetic
ketoacidosis was thought to be triggered by a viral
gastroenteritis as well as pneumonia ([**Last Name 788**] problem #2).
Initially because of poor po intake, he was only given 10
units of Lantus insulin and his blood sugars were
persistently between 200-300. Lantus was increased to 20
units on the day prior to discharge with continuing Humalog
sliding scale coverage. This regimen to achieve better
glycemic control, and prior to discharge, a repeat Chem-7 was
checked showing complete closure of his anion gap.
2. Pulmonary: Because of his anemia, which is likely
secondary to his renal disease, he was transfused 1 unit of
packed red blood cells on the 15th. Following this blood
transfusion and in addition to the aggressive intravenous
fluid resuscitation he received, the patient developed
pulmonary edema, and was restarted on his outpatient dose of
Lasix 80 mg po bid.
The patient continued to have an anion gap despite
appropriate therapy with insulin and it was unclear if
further infection was the cause of his diabetic ketoacidosis.
With the pleural effusions at the lung bases were obscured,
to better evaluate lung parenchyma, a CT scan of the chest
was done which revealed a right lower lobe parenchymal air
space consolidation with again no evidence of bilateral
pleural effusions associated with compressive atelectasis.
There are also prominent mediastinal and axillary lymph nodes
noted.
The patient was then started on antibiotics initially given
ceftriaxone and clindamycin. Concern was briefly arranged
for an aspiration pneumonia given the patient's significant
vomiting, however, it was felt that he most likely had a
community acquired pneumonia, and then was continued on
clindamycin alone. Upon transfer from the Intensive Care
Unit to the Medical team, his antibiotics were further
changed to levofloxacin as monotherapy for his pneumonia.
Sputum culture was obtained which revealed fewer than 10
polys, and culture grew moderate oropharyngeal flora. The
patient was discharged with levofloxacin to complete a 10 day
course. Prior to discharge on [**2155-3-17**], the patient had a
right thoracentesis which removed approximately 1 liter of
fluid. Culture of this fluid yielded no growth. Gram stain
revealed no organisms or leukocytes. Chemistry analysis of
the fluid and cell counts revealed white blood cell count of
125, red blood cell count of 1,490 with a differential with
the white blood cell count of 0 polys, 77 lymphocytes, 17
monocytes, and 5 mesothelial cells. The pleural fluid
glucose was 146, LDH 93, and albumin 0.9. Analysis of these
numbers revealed that the fluid is most likely suggestive of
a transudate likely representing a parapneumonic effusion.
For the local pain of the thoracentesis site, the patient was
given Percocet with good relief.
During the admission, the patient had also complained of a
pleuritic type of pain on the right side. Brief concern for
pulmonary embolism was raised, and the patient was started on
Heparin. Bilateral lower extremity noninvasive studies were
performed which were negative for any evidence of deep venous
thrombosis at which time the Heparin was stopped. The
pleuritic pain was likely felt to be due to his pneumonia and
effusion.
3. Cardiovascular:
A. Hypertension: The patient continued to be hypertensive
during his admission. He was continued on his outpatient
medications including Isordil, Norvasc, and hydralazine.
B. Congestive heart failure: As stated above, following
transfusion and aggressive volume resuscitation, the patient
had some pulmonary edema. This cleared after reinstating his
outpatient dose of Lasix at 80 mg po bid.
4. Renal: Renal was consulted upon admission. His
creatinine progressively improved from 8.1 on admission down
to 6.6 on the day of discharge. His elevated creatinine
likely represented progression of chronic disease with the
added insult of dehydration. One final Chem-7 was checked
before discharge, as the patient left late at night in order
to check his anion gap, and it showed that his creatinine had
bumped again to 7.2. He will have very close followup with
Nephrology and plans to start peritoneal dialysis in the
future as there is no match related donor for transplant. He
was continued on his Epo 5,000 units q Monday and Friday. He
was given PhosLo two tablets tid with meals.
5. Gastrointestinal: The patient had no further nausea and
vomiting after admission including therefore obviously no
further coffee-ground emesis. It was felt that the
coffee-grounds was likely due to a small [**Doctor First Name **]-[**Doctor Last Name **] tear
given the refractory vomiting the patient had prior to
admission. He was continued on Protonix 40 mg po q day for
prophylaxis.
DISCHARGE DIAGNOSES:
1. Diabetic ketoacidosis.
2. Viral gastroenteritis.
3. Right lower lobe pneumonia.
4. Small upper gastrointestinal bleed likely secondary to
[**Doctor First Name **]-[**Doctor Last Name **] tear.
5. Right sided parapneumonic effusion.
DISCHARGE MEDICATIONS:
1. Labetalol 600 mg po bid.
2. Hydralazine 25 mg po qid.
3. Isordil 20 mg po tid.
4. Norvasc 10 mg po q day.
5. Protonix 40 mg po q day.
6. Epo 5,000 units subQ q Monday and Friday.
7. Ofloxacin 0.3% eyedrops one drop OD qid.
8. Prednisolone acetate 1% eyedrops one drop OD qid.
9. Reglan 10 mg po qid.
10. Atropine sulfate 1% eyedrops one drop OD [**Hospital1 **].
11. Aspirin 325 mg po q day.
12. Lasix 80 mg po bid.
13. PhosLo 667 mg three tablets tid with meals.
14. Percocet 1-2 tablets po q4-6h prn.
15. Glargine insulin 20 units q am.
16. Humalog sliding scale.
17. Levofloxacin 250 mg po qod for eight days.
FOLLOWUP: The patient is instructed to followup at the
[**Hospital **] Clinic with Dr. [**First Name8 (NamePattern2) 518**] [**Last Name (NamePattern1) 28587**]. He is to call
[**Telephone/Fax (1) 9979**] for the next available appointment. He is also
to arrange followup at the [**Last Name (un) **] for teaching in calorie
counting. He is to arrange a follow-up appointment with his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the next 1-2 weeks
as well.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 13467**]
Dictated By:[**Name8 (MD) 3491**]
MEDQUIST36
D: [**2155-3-19**] 14:57
T: [**2155-3-20**] 09:29
JOB#: [**Job Number 28588**]
|
[
"40391",
"5119",
"486",
"4280"
] |
Name: [**Known lastname 3152**], [**Known firstname 448**] Unit No: [**Numeric Identifier 3153**]
Admission Date: [**2143-12-14**] Discharge Date: [**2143-12-17**]
Date of Birth: [**2082-11-5**] Sex: M
Service:
ADMISSION DIAGNOSIS:
1. Bright red blood per rectum status post prostate needle
biopsy.
POSTOPERATIVE DIAGNOSIS:
1. Bright red blood per rectum status post prostate needle
biopsy.
HISTORY OF PRESENT ILLNESS: This is a 61 year-old male with
history of elevated PSA who underwent a prostate needle
biopsy on [**2143-12-11**]. He was noted to pass dark clots per
rectum on [**2143-12-12**]. He was seen in the emergency room and
evaluated. He was found to have normal hematocrit of 40,
normal coags with INR of 1.1. The remainder of his labs were
normal. He was discharged home in stable condition with no
further bleeding after discussion with Dr. [**Last Name (STitle) **].
On [**2143-12-14**] the patient started passing bright red blood
per rectum times three starting at seven o'clock that
evening. He was instructed to go to the emergency room where
he continued to pass bright red blood per rectum with clots.
The total volume noted in the emergency room was about one
liter of blood clots. In the emergency room a general
surgery consult was obtained. They performed anoscopy which
showed that there was bleeding above the anoscope. They then
put a flexible sigmoidoscopy with a balloon pump in the
emergency room for tamponade.
PAST MEDICAL HISTORY:
1. Elevated PSA.
2. Prostatitis.
3. BPH.
4. Chronic gastric pain.
PAST SURGICAL HISTORY:
1. Prostatic needle biopsy on [**2143-12-11**].
2. Bilateral inguinal hernia repairs.
MEDICATIONS ON ADMISSION:
1. Flomax 0.4 milligrams po q day.
2. Elavil 10 milligrams po q day.
3. Clonazepam 1 tablet po q day.
4. Roxicet prn.
ALLERGIES:
1. Penicillin.
2. Demerol.
PHYSICAL EXAMINATION: On admission he was afebrile. He was
hypotensive with a systolic of 88/palp which went up to
104/60 on Trendelenburg. Remainder of his exam was
significant for rectal examination with gross blood and
clots. The urine had gross hematuria.
LABORATORY DATA ON ADMISSION: He had a white count of 8.7,
hematocrit 37.9, platelet count 307,000, sodium 137,
potassium 3.8, chloride 101, bicarb 25, BUN 20, creatinine
1.2, glucose 102. PT 12.8, PTT 28.7, INR 1.1.
HOSPITAL COURSE: He was admitted to the Urology service for
blood transfusion and further evaluation of his bleeding per
rectum. The General Surgery service performed a formal
evaluation and again performed an anoscopy which showed no
bleeding at 5 cm but bleeding from above. They performed a
rigid sigmoidoscopy and up to the 15 cm there was no bleeding
to be noted. However after the scope was removed there was
blood observed to be pooling. They put a rectal tube in with
a balloon occlusion and Surgicel packing of the rectum. The
rectal tube with the balloon was then taken out. There was no
further bleeding to be noted. They replaced the Surgicel
packing.
The patient was brought to the Intensive Care Unit for more
careful observation given that his systolic blood pressure
was quite labile. While in the Intensive Care Unit a right
internal jugular triple Lumen catheter was placed and he was
given a total of five units of packed red blood cells. While
in the Intensive Care Unit he had serial hematocrits drawn.
His lowest hematocrit was 28 and he was transfused to keep
his hematocrit above 30. Again he received a total of five
units of packed red blood cells. He was also put on Levaquin
prophylactically.
On hospital day three he was deemed stable enough for
transfer out of the unit. He had a bowel movement which was
brown, old blood. He had no further episodes of bright red
blood per rectum. He was transferred to the floor where his
hematocrit remained stable at 33.
On hospital day five his hematocrit came back at 31 and he
had another bowel movement without any bright red blood per
rectum.
DISCHARGE CONDITION: He was deemed stable for discharge.
DISCHARGE INSTRUCTIONS: He was sent home with
recommendations to avoid all ANSAIDs and to avoid vigorous
activity for the next four weeks or so. He was discharged
home with one more day of Levaquin.
[**Last Name (LF) **],[**First Name3 (LF) 63**] 34.121
Dictated By:[**Male First Name (un) 3154**]
MEDQUIST36
D: [**2143-12-17**] 10:49
T: [**2143-12-23**] 09:50
JOB#: [**Job Number 3155**]
|
[
"2859"
] |
Unit No: [**Unit Number 111442**]
Admission Date: [**2186-3-25**]
Discharge Date: [**2186-3-29**]
Date of Birth: [**2120-3-10**]
Sex:
Service:
HISTORY: The patient is a 66-year-old woman who is
transferred from an outside hospital for abdominal pain and
distention. Her history begins with several days of watery
diarrhea followed by the onset of midabdominal pain last
evening, which progressed to nausea but no emesis. The
patient states the pain is consistent, nonradiating, worse
with movement. She has had no fever and no chills, no
dysuria, no chest pain and no flatus. The pain was severe
enough to cause her to seek care in an outside emergency room
and she is now transferred to the [**Hospital3 **] at the request
of her family.
PAST MEDICAL HISTORY: Is significant for atrial
fibrillation, hypertension, Crohn disease, history of urinary
tract infections, degenerative joint disease, COPD, aortic
regurgitation, small bowel obstructions in the past,
depression, MRSA line sepsis and lower extremity cellulitis.
PAST SURGICAL HISTORY: Is significant for an ileal resection
for Crohn's in [**2171**], a gastric band for obesity in [**2182**], and
a right upper extremity skin graft and a total abdominal
hysterectomy.
ALLERGIES: Are to tetracycline and Demerol.
MEDICATIONS: Include Coumadin 7.5 mg daily, except for
Monday where she takes 10 mg, digoxin 250 mcg a day, Cartia
240 mg once a day, Prozac, Wellbutrin, Topamax 200 mg twice a
day, folic acid, Pentasa 750 mg 4 times a day, budesonide,
Lasix 40 mg every other day and potassium replacement.
PHYSICAL EXAMINATION: On examination initially in the
emergency room, she had a temperature of 97.9, heart rate of
101, respiratory rate at 24, blood pressure of 151/48 and a
room air saturation of 98%. She was in obvious discomfort.
Her cardiac exam was irregularly irregular. Chest exam was
clear to auscultation and percussion bilaterally. Abdominal
exam was massively distended, diffusely tender with guarding.
Her rectal exam was heme-negative without masses and she had
no evidence of hernias on palpation of her inguinal canal or
right abdominal wall.
Workup in the emergency room ruled her out for myocardial
infarction.
LABORATORY DATA: Her lactate level was 3.9. Blood gas was
within normal limits at 7.35/34/71/20/negative 5. Her white
blood cell count was 11.1 with a left shift and her
electrolytes were within normal limits except for her
potassium, which was low at 2.8. Her INR was 1.4. She had a
KUB which showed dilated loops of small bowel throughout. No
free air and no evidence of volvulus.
HOSPITAL COURSE: While in the emergency room, the patient
began to pass copious light brown stool with significant
decrease in distention of her abdomen and decrease in pain.
Of note, her family has several members who are ill with
gastroenteritis. The patient's gastric band prevents her
from vomiting and we were unable to pass a nasogastric tube
it. However, the nasogastric tube was put down into her
esophagus and did pull back bilious material.
She had a CT scan, which revealed that her entire GI tract
from stomach to her rectum was diffusely dilated and fluid-
filled. There was no focal obstruction or findings. This was
all consistent with gastroenteritis and the inability to
vomit secondary to her gastric band.
A rectal tube and a nasoesophageal tube were placed. She was
hydrated with intravenous fluids and given stress dose
steroids because she had been treated within the past year
for her Crohn's with steroids. She was also noted to have an
E. coli UTI, which was also treated with antibiotics.
The urinary tract infection was treated with levofloxacin 500
mg IV q.24 hours.
The patient was adequately higher hydrated and began to have
a reasonable urine output. Her nasoesophageal tube put out
over a liter per day of bilious fluid. The rectal tube output
was also good. She continued to deflate the distention in her
abdomen and it was completely nontender. Her C. diff cultures
were negative. Her condition continued to improve over serial
days of IV hydration and on hospital day #3, she started to
tolerate clear liquids without difficulty and was advanced to
a mechanical soft-solid diet, did well with this and was
discharged home on hospital day #4. The patient is discharged
home on all of her preoperative medications. She has been
instructed to go to the emergency room if she experiences any
of the symptoms that she had previously. She will be seen in
follow-up by her primary care physician.
DISCHARGE DIAGNOSIS: Gastroenteritis and hypovolemia
secondary to diarrhea.
CONDITION ON DISCHARGE: Good.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD
Dictated By:[**Name8 (MD) 111443**]
MEDQUIST36
D: [**2186-6-20**] 18:11:15
T: [**2186-6-25**] 05:36:43
Job#: [**Job Number **]
|
[
"42731",
"496",
"5990",
"4019",
"311",
"V5861"
] |
Admission Date: [**2196-11-4**] Discharge Date: [**2196-11-7**]
Date of Birth: [**2143-2-6**] Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
Mr. [**Known lastname 101729**] is a 53 yo M with hypertension, hyperlipidemia and
history of hyperglycemia in setting of prednisone use in [**Month (only) 205**]
[**2196**] when he was admitted for angioedema now presenting to ED
with polyuria, polydipsia, and malaise x 1-2 weeks with
progressive weakness and orthostasis. He also had nbnb emesis x
1 on day prior to admission with nausea and intermittent leg
cramping.
.
In the emergency department vitals at presentation were T 98, HR
102, BP 163/97, RR 18, O2Sat 98% RA. Initial labratory
evaluation showed glucose of 932, lactate of 4.1, and Cr of 1.5
with an anion gap of 27 and K 6.0. CXR was obtained and was
unremarkable. He was started on insulin drip in ED (7.5 at time
of transfer) and received 2L NS. VS prior to transfer: T 97.2,
HR 95, BP 169/122, RR 18, O2Sat 94% RA.
.
Of note, he has no prior diagnosis of diabetes but was
discharged on metformin in [**6-/2196**] to take while he was on
prednisone since he had elevated plasma glucose up to 285. He
was also taking sliding scale insulin at the time but blood
sugars returned to [**Location 213**] off prednisone so both metformin and
insulin were discontinued and he has not been checking his blood
sugars since [**Month (only) 205**].
.
On arrival to the ICU, he reports improved thirst and lethargy
and denies chest pain, palpitations, SOB, cough, dysuria,
rhinorrhea, sinus congestion, abdominal pain, diarrhea, fever,
chills.
.
Past Medical History:
1) Hypertension
2) Hyperlipidemia
3) Angioedema - [**6-/2196**]
4) Erectile dysfunction
5) Tendinitis in the left knee
6) Left forearm fracture status post repair including bone
grafting procedure
7) Shingles (admission [**2195-12-1**])
8. s/p shrapnel removal R shoulder
Social History:
He smoked "a couple cigarettes per day" for the past 20 years
but quit approximately 1 year ago. He drinks a couple beers on
occasion. Denies illicit drugs. He works as a general manager of
a small trucking company. He has been divorced for the past 16
years. He is in a monogamous relationship with his girlfriend
and lives alone. He has no children. He was in the US Marine
Corps.
Family History:
Strong family history of diabetes on his father's side with
multiple members diagnosed in their 30s-40s. Mother is living
and has emphysema. Father died of pancreatic cancer at age 57.
Father also had type 2 diabetes. One half brother and paternal
uncle and aunt have type 2 diabetes. Paternal uncle has [**Name2 (NI) 499**]
cancer and died in his mid 60s. Paternal aunt had pancreatic
cancer. Another paternal aunt had a blood cancer and another
paternal uncle has stomach cancer and is currently in remission.
Physical Exam:
VS: 149/96 96 16 94%
GEN: Pleasant, mildly ill appearing gentleman in NAD
HEENT: nc/at MM dry, OP clear, no thrush or exudate
NECK: JVP flat. Supple.
PULM: CTAB. No w/r/r. No Kusmaal respirations.
CARD: RRR No m/r/g
ABD: Soft. NTND +BS No HSM
EXT: No c/c/e
SKIN: No rash. Dry, cracked.
NEURO: AAOx3. CN 2-12 grossly intact
PSYCH: Appropriate.
Pertinent Results:
ADMISSION LABS:
.
[**2196-11-4**] 08:15AM BLOOD WBC-10.9# RBC-5.47 Hgb-16.8 Hct-49.5
MCV-91 MCH-30.7 MCHC-33.9 RDW-12.1 Plt Ct-216
[**2196-11-4**] 08:15AM BLOOD Neuts-90.7* Lymphs-7.3* Monos-1.5*
Eos-0.1 Baso-0.5
[**2196-11-5**] 02:44AM BLOOD PT-12.5 PTT-22.5 INR(PT)-1.1
[**2196-11-4**] 08:15AM BLOOD Glucose-932* UreaN-29* Creat-1.5* Na-129*
K-6.0* Cl-83* HCO3-19* AnGap-33*
[**2196-11-4**] 08:15AM BLOOD cTropnT-<0.01
[**2196-11-4**] 08:15AM BLOOD Calcium-10.8* Phos-7.8*# Mg-2.5
[**2196-11-4**] 10:20AM BLOOD %HbA1c-12.8* eAG-321*
[**2196-11-4**] 03:22PM BLOOD Type-[**Last Name (un) **] Temp-36.6 pO2-55* pCO2-43
pH-7.39 calTCO2-27 Base XS-0 Comment-PERIPHERAL
[**2196-11-4**] 08:22AM BLOOD Glucose-GREATER TH Lactate-4.1* Na-130*
K-5.6* Cl-90* calHCO3-17*
.
DISCHARGE LABS:
.
[**2196-11-6**] 03:59AM BLOOD WBC-8.6 RBC-4.90 Hgb-14.9 Hct-42.4 MCV-87
MCH-30.4 MCHC-35.1* RDW-11.8 Plt Ct-168
[**2196-11-7**] 07:05AM BLOOD Glucose-266* UreaN-16 Creat-1.0 Na-136
K-4.0 Cl-99 HCO3-26 AnGap-15
[**2196-11-7**] 07:05AM BLOOD Calcium-9.6 Phos-3.0 Mg-1.9
Brief Hospital Course:
53 year old man with HTN, hyperlipidemia and h/o hyperglycemia
presented with hyperglycemia and DKA.
.
#. DKA: Patient presented with hyperglcemia with blood sugars
900s with elevated anion gap of 27 consistent with DKA and
relatively new onset diabetes. Of note, he had elevated blood
sugars last admission and had been started on metformin but only
while on prednisone. It is unclear if he has Type 1 or Type 2 DM
given presentation with DKA at older age and may have flatbush
diabetes which can present with intermittent episodes of DKA.
He was hyperkalemic, and hypovolemic, with a Cr of 1.5 up from
1.1 baseline. Hyponatremia was thought to be due to both
hypovolemia and pseudohyponatremia in the setting of severe
hyperglycemia. Patient was initially on insulin gtt until blood
sugars in 100s-200s and he was transitioned lantus 20 units qhs
and metformin 500mg. His Hgba1C was 12. Electrolyte
abnormalities resolved with closure of anion gap and IVFs.
Patient was transferred from the ICU to the floor during which
his blood sugars were controlled on an insulin sliding scale,
lantus 22 units, and metformin 500 qd. He was discharged on
metformin 500 mg [**Hospital1 **], lantus 24 at night, humalog sliding scale,
and follow-up with [**Last Name (un) **] the week following discharge.
.
# Hypertension: Slightly hypertensive on arrival. Continued
amlodipine. HCTZ was initally held as can worsen hyperglycemia,
but restarted upon discharge.
[**Last Name (un) **] on Admission:
HCTZ 25mg PO daily
Simvastatin 20mg PO daily
Amlodipine 10mg PO daily
Discharge [**Last Name (un) **]:
1. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Lantus 100 unit/mL Cartridge Sig: Twenty Four (24) units
Subcutaneous at bedtime.
Disp:*1 Please dispense 1 month supply* Refills:*2*
5. Humalog 100 unit/mL Cartridge Sig: as directed units per
sliding scale Subcutaneous as directed: Please take according to
sliding scale.
Disp:*1 1 month supply* Refills:*2*
6. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day:
Please increase to 1000 mg ( 2 x 500 mg) twice daily starting on
Friday [**11-11**].
Disp:*112 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Diabetes Mellitus
Diabetic Ketoacidosis
Secondary:
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were brought to the hospital because of a very elevated
blood glucose level. You were cared for in the medical intensive
care unit initially where your blood sugar level improved with
intravenous fluids and insulin. You were transferred to the
general floor, where your blood sugars were controlled with
insulin and metformin. You will need to be on an insulin
sliding scale, while continuing to take metformin and lantus.
.
We made the following changes to your [**Month/Year (2) 4982**]:
.
ADDED Lantus 24 units at night
ADDED Insulin to be taken per sliding scale provided
ADDED Metformin 500 mg twic [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5490**], to be increased to 1000 mg
twice a day after 4 days
.
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
Department: [**Hospital3 249**]
When: MONDAY [**2196-11-14**] at 3:25 PM
With: [**First Name8 (NamePattern2) 1037**] [**First Name8 (NamePattern2) 3239**] [**Last Name (NamePattern1) 30891**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ENDOCRINE/[**Last Name (un) **]
When: TUESDAY, [**2196-11-15**] at 4pm
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], NP
[**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2384**]
|
[
"2761",
"4019",
"2724"
] |
Admission Date: [**2154-6-17**] Discharge Date: [**2154-6-22**]
Date of Birth: [**2072-3-6**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
1. Endovascular aortic aneurysm repair of juxtarenal
aneurysm with fenestrated stent graft.
2. Bilateral catheter in aorta.
3. Bilateral femoral artery exposure.
4. Left renal artery embolization.
5. Right renal artery stent graft [**5-18**] iCAST.
6. Superior mesenteric artery bare metal stent [**10-10**]
Genesis.
History of Present Illness:
Mr. [**Known lastname 111939**] is an 82-year-old gentleman referred by Dr. [**Last Name (STitle) **]
for evaluation of an aortic pseudoaneurysm. He is status post
repair of an infrarenal abdominal aortic aneurysm with an
aortobifemoral graft at [**Hospital6 2561**] in the late [**2121**].
I believe this was done by Dr. [**Last Name (STitle) 111940**]. He had a CT scan
approximately one year ago that demonstrated aneurysm above to
the existing graft, and this was recently repeated, demonstrated
approximately 6-cm aneurysm. He denies any abdominal or back
pain. He has an extensive past medical history of coronary
artery disease status post MI, TIAs on coumadin, CABG x 3
([**2135**]). He is a former smoker who quit in [**2116**]. He has
pacemaker. He has had coronary artery bypass grafting in [**2135**].
He has CHF. He has got several skin cancers removed. He has
had hernia repair. He has prostate hypertrophy, psoriasis, and
cholecystectomy.
Past Medical History:
PMH: TIAs on coumadin, CAD (s/p MI), CHF (EF 40-45%), BPH,
psoriasis, prostate ca (s/p radiation), TIA( on coumadin)
PSH: CABG ([**2135**]), pacemaker, hernia repair, cholecystectomy,
multiple skin ca (bcc) removals
Social History:
Lives at home with his wife.
Family History:
tobacco - quit [**2116**]
etoh - Drinks one glass of wine with lunch and a [**Doctor Last Name 6654**] before
dinner and a shot of scotch after dinner every day.
Physical Exam:
General: well appearing, no apparent distress
Vitals: 98.7 98.3 84 138/68 20 98%RA
Cardio: rrr, normal s1 s2
Pulm: faint rhonchi, mild tachypnea
Abd: soft, nontender, nondistended,
Ext: groins w/dsg bilaterally, clean dry intact; pulse exam: L-
palpable throughout, R-palpable femoral and popliteal with
doplerable DP and PT
Pertinent Results:
[**2154-6-21**] 05:16AM BLOOD WBC-10.6 RBC-3.02* Hgb-10.0* Hct-28.8*
MCV-95 MCH-32.9* MCHC-34.6 RDW-17.1* Plt Ct-100*
[**2154-6-22**] 05:08AM BLOOD WBC-8.7 RBC-2.96* Hgb-9.6* Hct-28.0*
MCV-95 MCH-32.5* MCHC-34.4 RDW-16.4* Plt Ct-145*
[**2154-6-21**] 05:16AM BLOOD PT-16.0* PTT-31.7 INR(PT)-1.5*
[**2154-6-22**] 05:08AM BLOOD PT-17.7* PTT-31.4 INR(PT)-1.7*
[**2154-6-21**] 05:16AM BLOOD Glucose-104* UreaN-44* Creat-2.8* Na-134
K-4.8 Cl-100 HCO3-29 AnGap-10
[**2154-6-22**] 05:08AM BLOOD Glucose-107* UreaN-47* Creat-2.6* Na-135
K-4.6 Cl-100 HCO3-26 AnGap-14
[**2154-6-20**] 09:29AM BLOOD CK(CPK)-144
[**2154-6-20**] 04:53PM BLOOD CK(CPK)-141
[**2154-6-18**] 09:45AM BLOOD CK-MB-2 cTropnT-0.02*
[**2154-6-20**] 09:29AM BLOOD CK-MB-2 cTropnT-0.01
[**2154-6-21**] 05:16AM BLOOD Calcium-8.2* Phos-2.6* Mg-2.5
[**2154-6-22**] 05:08AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.4
Brief Hospital Course:
The patient was admitted to the Vascular Surgery Service for
scheudled endovascular surgical treatment of and abdominal
aortic aneurysm. On [**2154-6-17**] the patient underwent endovascular
aortic aneurysm repair with fenestrated graft, which went well
without complications (see operative note for further details).
Of note, pt's After a breif uneventful stay in the PACU, the
patient arrived to the floor NPO on IV fluids and on
antibiotics, with a foley catheter, and with minimal pain. The
patient was hemodynamically stable.
Neuro: The patient received minimal doses of Dilaudid IV for
pain. Dilaudid was eventually D/C'ed because the patient was
not complaining of pain.
CV: The patient has a pacemaker; had one episode of SVT with HR
~150's for approx 40sec during which he was completly
asymptomatic. Cardiology saw the patient, adjusted the
pacemaker to include a monitoring range from 140-160, and made
no further changes or recs. No additional medications were
given during the episode and the episode did not recur. Pt had
a central venous line installed for access but that was removed
prior to discharge. Pt remained stable after that episode and
was stable on discharge.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Early
ambulation and incentive spirometry were encouraged throughout
hospitalization. No acute issues.
GU: Pt with poor urine output after surgery secondary to L
renal artery embolization related to graft placement. Cr was
elevated as well as high as 2.9. Foley catheter was placed and
daily weights were recorded to evaluate fluid status. Renal
ultrasound performed indicated that the remaining R-kidney had
adequate blood flow. Per Renal Service recommendation, we DC'ed
the pt's home dose of Ramipril for concern of glomerular
hypoperfusion. Urine output was routinly monitored and
adequate on discharge and Cr declined to 2.6.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated. Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary. Now on a
regular Diabetic Diet.
ID: Pt found to have UTI on UA and treated with 3 days of
Ciprofloxacin in house. Otherwise, the patient's white blood
count and fever curves were closely watched for signs of
infection.
Wound care: bilateral EVAR incision sites were monitored and
well maintained. No signs of infection.
Endocrine: The patient's blood sugar was monitored throughout
his stay and found to be somewhat elevated ranging from
110's-230's so placed on a sliding scale of insulin. However pt
never diagnosed with diabetes, so consider discontinuing the
regimen on discharge from the Rehab.
Prophylaxis: The patient received subcutaneous heparin during
this stay; would continue HSQ until patient is theraputic on his
Coumadin then DC at that time.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding through a condom catheter (for urine
output monitoring), and complaining of no pain. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Medications on Admission:
coumadin 4', carvedilol 6.25'', vytorin 10/40', ramipril 2.5',
Ca carbonate (dose unk), Vit D3, VitB12
Discharge Medications:
1. Acetaminophen IV 1000 mg IV Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Carvedilol 6.25 mg PO BID
5. Vytorin 10-40 *NF* (ezetimibe-simvastatin) 10-40 mg Oral
daily hypercholesterolemia
6. Warfarin 4 mg PO DAILY16
7. Cyanocobalamin 50 mcg PO DAILY
8. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 11057**] Place Nursing Center
Discharge Diagnosis:
Abdominal aortic aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**5-24**]
weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? You may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**1-18**]
pillows or a recliner) every 2-3 hours throughout the day and at
night if you find your legs swellilng.
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? You should get up every day, get dressed and walk, gradually
increasing your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (let the soapy water run over incision, rinse
and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
UNLESS OTHERWISE DIRECTED
?????? Take one baby aspirin daily (81mg), unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal if applicable.
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Call his office on
MONDAY at ([**Telephone/Fax (1) 9393**] to schedule an appointment.
***You will need to have a follow up noncontrast CT SCAN of your
abdomen and pelvis. At this appointment you will also need to
have a Duplex of your aorta. Please call Dr.[**Name (NI) 7446**]
office to schedule this appointment.
Completed by:[**2154-6-22**]
|
[
"2724",
"V4581",
"V5861",
"V1582",
"5845",
"4280",
"5990",
"9971",
"4019",
"412"
] |
Admission Date: [**2187-2-27**] Discharge Date: [**2187-3-3**]
Date of Birth: [**2122-7-31**] Sex: M
Service: SURGERY
Allergies:
Neomycin
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
abdominal aneurysm
Major Surgical or Invasive Procedure:
PROCEDURE: Retroperitoneal repair of juxtarenal abdominal aortic
aneurysm with 18 mm Dacron tube graft and supraceliac
crossclamp.
History of Present Illness:
This is a 64 year old patient with PMR on treatment with
prednisone 10mg who was recently admitted with chest pain, CTA
revealing aortic ulcerations as well as an abdominal aortic
aneurysm that is >6cm. He was admitted for surgical repair of
the aneurysm.
Past Medical History:
PMR - on prednisone 10mg po qd
Glucose intolerance secondary to steroid therapy
Social History:
Patient is a retired inspector at a shipyard in [**Location (un) 12017**], NH
with known asbestos exposure. He is married with 3 children and
currently lives with his wife. [**Name (NI) **] currently smokes and reports a
50 pack-year history. He reports he has attempted many times to
quit using agents such as a Nicotine patch as well as Zyban
without effect. He reports alcohol consumption of approximately
1 case of beer/week but denies any history of illict drug use.
His longest period of abstinence recently was 3 weeks and he
denies any associated tremors, agitation or seizure history.
Family History:
No history of CVD or aortic disease in his family. The patient's
mother died at age [**Age over 90 **] of "natural causes". His father died at
age 87 of a CVA. The patient had 2 siblings pass away from
Breast Cancer.
Physical Exam:
On admission exam there is a pulsatile mass in the abdomen
consistent with the patient's demonstrated aneurysm on CT. This
mass is non-tender.
Brief Hospital Course:
Patient was admitted the morning of surgery. On [**2187-2-27**] he
underwent successful retroperitoneal repair of juxtarenal
abdominal aortic aneurysm with 18 mm Dacron tube graft and
supraceliac crossclamp. There were no intraoperative
complications and the procedure was well-tolerated by the
patient. Please see operative note for operative details. The
patient was taken to the recovery room in stable condition and
transferred to the vascular intensive care unit later the same
day. He received stress-dose steroids peri-operatively as well
as antibiotics. Pain was well-controlled with an epidural
catheter. His post-operative course was entirely unremarkable.
He did not receive a nasogastric tube during the procedure and
still did not experience post-op nausea or vomiting. He remained
in normal sinus rhythm throughout and his level of
cardiopulmonary monitoring was weaned over the next several
days. He was discharged home on [**2187-3-3**] after being cleared by
physical therapy. At discharge he was afebrile, tolerating a
full diet and ambulating without difficulty. His incision was
beginning to heal nicely. He has follow-up as outlined below.
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
POSTOPERATIVE DIAGNOSIS: Juxtarenal abdominal aortic aneurysm.
Discharge Condition:
Stable
Discharge Instructions:
Please avoid heavy lifting or strenuous activity for at least 6
weeks. Please watch for signs of infection as described in the
nursing discharge information and call right away (or go to the
emergency room) if you develop fever > 101.4, or your wound
begins draining thick or foul-smelling discharge. You may shower
as normal but do not bathe. Keep the incision clean and dry.
Take stool softener while taking narcotic pain medication and do
not drive while taking this pain medication. Follow-up with Dr.
[**Last Name (STitle) **] as outlined below. Please restart all your home
medications as well as those prescribed below and follow-up with
your primary care doctor as soon as possible for a post-surgery
check-up and medication monitoring.
Followup Instructions:
Please follow-up in 2 weeks in clinic with Dr. [**Last Name (STitle) **]. You
will need to call ahead of time to make an appointment. ([**Telephone/Fax (1) 18152**]
Completed by:[**2187-3-3**]
|
[
"4019"
] |
Admission Date: [**2189-12-21**] Discharge Date: [**2189-12-23**]
Date of Birth: [**2147-10-25**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5037**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 42 yof with hx of FSGS s/p kidney transplant in [**2186**],
DM II, HTN, hypercholesterolemia, Iron deficiency anemia who
presents from home with hyperglycemia now found to be in
Hypersomolar Hyperglycemic Non-ketosis. Patient went this
morning for routine labwork and had a glucose [**Location (un) 1131**] of 583.
She was called by her Nephrologist and told to come into the ED
for evaluation. She was diagnosed with Diabetes shortly after
her transplant. She was on Avandia and insulin for a brief time
but this was stopped by her nephrologist about 1 year ago due to
improvement in her symptoms. Currently, she denies any symptoms
of polydypsia, polyphagia, polyuria or nocturia. She does
report recent URI two weeks ago with nasal congestion. She
denies any recent cough, CP, SOB, Nausea, vomiting, diarrhea,
abdominal pain, or dysuria. Otherwise, she feels well and has
no complaints.
.
In the ED, initial vs were: Temp 98, P 116, BP 167/85, R 18
98%RA. Patient was given 8u Regular Insulin at 340pm. She was
started on Insulin gtt at 8u/hr at 510pm. She received 2L NS
while in the ED and was transferred to the MICU.
.
Past Medical History:
FSGS s/p kidney transplant
DM II
HTN
Hypercholesterolemia
Iron Deficiency Anemia
Obesity
Social History:
She denies tobacco, EtOH or illicit drug use. She works as a
secretary for an engineering firm. She is a widow, has one son
and lives with her mother.
Family History:
Mother with HTN
Physical Exam:
Vitals: Temp 96.8 BP: 157/87 P: 86 R: 14 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no rubs, gallops.
+I/VI SEM LUSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2189-12-21**] 09:15AM WBC-4.4 RBC-4.63 HGB-13.4 HCT-39.2 MCV-85
MCH-28.9 MCHC-34.2 RDW-13.6
[**2189-12-21**] 09:15AM PLT COUNT-236
[**2189-12-21**] 09:15AM CYCLSPRN-107
[**2189-12-21**] 09:15AM GLUCOSE-583*
[**2189-12-21**] 09:15AM UREA N-27* CREAT-1.4* SODIUM-132*
POTASSIUM-4.7 CHLORIDE-93* TOTAL CO2-26 ANION GAP-18
[**2189-12-21**] 03:15PM WBC-8.2# RBC-4.53 HGB-13.0 HCT-38.8 MCV-86
MCH-28.8 MCHC-33.6 RDW-13.4
[**2189-12-21**] 03:15PM NEUTS-75.8* LYMPHS-18.6 MONOS-3.6 EOS-1.1
BASOS-0.9.
[**2189-12-23**] 06:00AM BLOOD WBC-4.0 RBC-3.70* Hgb-10.6* Hct-31.4*
MCV-85 MCH-28.8 MCHC-33.9 RDW-13.8 Plt Ct-194
[**2189-12-23**] 06:00AM BLOOD Glucose-193* UreaN-12 Creat-1.0 Na-139
K-4.1 Cl-111* HCO3-20* AnGap-12
[**2189-12-23**] 06:00AM BLOOD calTIBC-241* Ferritn-61 TRF-185*
Brief Hospital Course:
The patient is a 42 year old woman with a history of FSGS s/p
kidney transplant in [**2186**] and DM Type 2 admitted with
Hypersomolar Hyperglycemic Non-ketosis. The patient was
initially admitted to the MICU and initiated on an insulin gtt.
She was given aggressive IVF repletion with subsequent
correction of hyperglycemia. She was evaluated by [**Last Name (un) **] and
restarted on Lantus 30 units HS. She was also started on prandin
with meals with adequate glycemic control achieved prior to
discharge.
The patient was continued on her home dose of immunosuppressants
s/p kidney transplant with cyclosporine and cellcept. Prednisone
was held in the setting of hyperglycemia and she will follow up
with her outpatient transplant nephrologist for directions on
when to restart this medication.
Medications on Admission:
Metoprolol 200mg daily
Valsartan 160mg daily
Bactrim daily
Pravastatin 40mg daily
Cellcept 1000mg qAM
Cellcept 500mg qPM
Lasix 20mg daily
Omeprazole 20mg daily
Prednisone 3mg daily
Cyclosporine 75mg daily
Discharge Medications:
1. Metoprolol Succinate 200 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
2. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
QAM (once a day (in the morning)).
6. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QPM (once a day (in the evening)).
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. Cyclosporine Modified 25 mg Capsule Sig: Three (3) Capsule
PO Q12H (every 12 hours).
11. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: 30 units
Subcutaneous at bedtime.
Disp:*3 pens* Refills:*2*
12. Prandin 2 mg Tablet Sig: One (1) Tablet PO TID (with
breakfast/lunch/dinner).
Disp:*90 Tablet(s)* Refills:*2*
13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day.
14. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
15. Lancets,Ultra Thin Misc Sig: One (1) Miscellaneous once
a day.
Disp:*30 lancets* Refills:*2*
16. One Touch Ultra 2 Kit Sig: One (1) kit Miscellaneous
once.
Disp:*1 kit* Refills:*0*
17. One Touch II Test Strip Sig: One (1) strips In [**Last Name (un) 5153**]
four times a day.
Disp:*120 strips* Refills:*2*
18. Alcohol Pads Pads, Medicated Sig: One (1) pad Topical
four times a day: Swipe finger before testing.
Disp:*1 box* Refills:*2*
19. Insulin Syringe Ultrafine [**11-20**] mL 29 x [**11-20**] Syringe Sig: One
(1) syringe Miscellaneous as directed.
Disp:*1 box* Refills:*2*
20. Outpatient Lab Work
Please have the following labs drawn: CBC, CHEM 7, urine
protein/cr ratio, tacrolimus level
You should have these drawn once between [**12-28**] and [**1-1**].
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hyperosmolar hyperglycemic non-ketosis, Type II
Diabetes mellitus, status post kidney transplant
Secondary: Hypertension
Discharge Condition:
stable
Discharge Instructions:
You were admitted because your blood sugar was elevated. You
went to the ICU and required intravenous insulin to reduce your
blood sugar. You were transitioned to injectable insulin and
your blood sugar is now stable. You were seen by
endocrinologists from [**Last Name (un) **] who recommended that you continue
using long acting insulin and an oral medicine to control your
blood sugar.
NEW MEDICATIONS:
-Lantus: you will need to inject 30 units before bedtime. Your
goal fasting blood sugar in the morning is 90-130. If your blood
sugar is greater than this range you should increase your lantus
dose by 10% (i.e. if dose is 30 you would go up by 3 units).
-Prandin: this is an oral medication to control your blood sugar
that you should take with breakfast, lunch and dinner.
Check and RECORD your blood sugar four times a day. Bring these
recorded values with you when you see Dr. [**Last Name (STitle) 14116**].
If you experience significantly elevated blood sugars (>300) or
low blood sugars, lightheadedness, sweating, chest pain,
shortness of breath or fevers, please contact your PCP or come
to the [**Name (NI) **] for evaluation.
Followup Instructions:
You have the following appointments:
-Please have lab work (per lab order) drawn once between [**12-28**] and
[**1-1**]
- You will meet with [**Doctor First Name 16883**] at [**Hospital **] clinic for diabetes
education on [**2189-12-25**] at 1pm
You need to have labs drawn next week.
- You are scheduled to see Dr. [**Last Name (STitle) 14116**] at [**Hospital **] clinic on
[**2189-12-31**] at 10am
-You are scheduled to see Dr. [**Last Name (STitle) **] [**Name (STitle) **] [**2190-1-11**] at 1:40pm
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]
|
[
"2762",
"4019",
"2720"
] |
Admission Date: [**2111-2-16**] Discharge Date: [**2111-2-21**]
Date of Birth: [**2052-6-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
DOE/fatigue/occasional angina and palpitations
Major Surgical or Invasive Procedure:
[**2-16**] AVR (OnX 23mm mechanical)
History of Present Illness:
58 yo M with known AS followed by serial echos. Admits to recent
episodes of lightheadedness, some DOE and vague chest pressure.
Referred for surgery.
Past Medical History:
Gastroesophageal Reflux Disease, s/p Splenectomy as a child, s/p
Rt. fem. art repair [**1-16**], Rt. leg neuropathy
Social History:
retired
denies tobacco
denies etoh
Family History:
NC
Physical Exam:
HR 80 BP 108/68
NAD
Lungs CTAB
Heart RRR, 4/6 SEM throught chest->carotids
Abdomen benign, well healed left flank scar
Extrem warm, no edema
Pertinent Results:
[**2-16**] Echo: Pre-CPB: No spontaneous echo contrast is seen in the
left atrial appendage. The RV has normal systolic fxn. The LV is
hypokinetic at the apex. Mild global systolic dysfxn. There are
simple atheroma in the descending thoracic aorta. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are severely thickened/deformed. There is moderate to
severe aortic valve stenosis (area 0.8-1.0cm2). Moderate (2+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is no pericardial effusion. Post CPB: A well seated Aortic valve
prosthesis is seen with no AI and no perivalvular leak. Good
biventricular systolic fxn. Aorta intact.
[**2-19**] CXR: Small left pleural effusion is new, is associated with
left lower lobe atelectasis. Mild cardiomegaly is stable. The
right lung is clear. The mediastinal wires are aligned. The
previously described central lucency in the sternum is no longer
visualized. There is no pneumothorax.
[**2111-2-16**] 10:10AM BLOOD WBC-17.7*# RBC-2.67*# Hgb-8.5*#
Hct-24.4*# MCV-92 MCH-31.9 MCHC-34.9 RDW-12.9 Plt Ct-209
[**2111-2-20**] 05:30AM BLOOD WBC-5.7 RBC-2.84* Hgb-8.8* Hct-26.6*
MCV-94 MCH-31.0 MCHC-33.0 RDW-12.9 Plt Ct-258
[**2111-2-16**] 10:10AM BLOOD PT-14.3* PTT-27.4 INR(PT)-1.2*
[**2111-2-19**] 03:10PM BLOOD PT-44.6* INR(PT)-5.0*
[**2111-2-19**] 09:15PM BLOOD PT-43.5* INR(PT)-4.8*
[**2111-2-20**] 05:30AM BLOOD PT-59.1* INR(PT)-7.0*
[**2111-2-20**] 10:05AM BLOOD PT-33.8* INR(PT)-3.5*
[**2111-2-21**] INR(PT)-3.0
[**2111-2-16**] 11:09AM BLOOD UreaN-8 Creat-0.9 Cl-110* HCO3-25
[**2111-2-20**] 05:30AM BLOOD Glucose-123* UreaN-13 Creat-0.9 Na-137
K-4.2 Cl-100 HCO3-32
Brief Hospital Course:
Mr. [**Known lastname 29239**] was a same day admit after undergoing all
pre-operative work-up as an outpatient. On [**2-16**] he was brought
to the operating room where he underwent an aortic valve
replacement. Please see operative report for surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition. Within 24 hours he was weaned
from sedation, awoke neurologically intact and extubated. On
post-op day one his chest tubes were removed and he was started
on beta blockers and diuretics. Later this day he was
transferred to the telemetry floor for further care. His
epicardial pacing wires were removed on post-op day two.
Coumadin was started for his mechanical valve. He had an initial
rise in his INR, which eventually trended down. Coumadin was
titrated for goal INR 2-2.5. He worked with physical therapy
during his post-op period for strength and mobility. On post-op
day five he was discharged home with VNA services and the
appropriate follow-up appointments. Dr. [**Last Name (STitle) 17321**] will follow his
INR on Monday and adjust Coumadin accordingly.
Medications on Admission:
Amitriptyline 100', Lipitor 40', Prilosec 40', ASA 81', Ca, MG,
MVI, physillium, Vit E.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO every
twenty-four(24) hours for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO every twenty-four(24)
hours for 7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. Amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
8. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
9. Coumadin 2 mg Tablet Sig: One (1) Tablet PO QPM as directed:
Goal INR 2.0-2.5.
Disp:*30 Tablet(s)* Refills:*2*
10. Lopressor 50 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
PMH: Gastroesophageal Reflux Disease, s/p Splenectomy as a
child, s/p Rt. fem. art repair [**1-16**], Rt. leg neuropathy
Aortic Stenosis s/p Aortic Valve Replacement
PMH: Gastroesophageal Reflux Disease, s/p Splenectomy as a
child, s/p Rt. fem. art repair [**1-16**], Rt. leg neuropathy
Discharge Condition:
Good
Discharge Instructions:
Call with fever, redness or drainage from incision or weight
gain more than 2 pounds in one day or five in one week.
Shower, no baths, no lotions,creams, or powders to incisions.
No lifting more than 10 pounds for 10 weeks.
No driving until follow up with surgeon.
Dr. [**Last Name (STitle) 17321**] will follow your INR and Coumadin. VNA will draw
blood and results faxed to Dr. [**Last Name (STitle) 17321**] at [**Telephone/Fax (1) 77487**]. Goal INR
2 - 2.5
Take 2mg Coumadin Saturday & Sunday then per Dr. [**Last Name (STitle) 17321**] on
Monday
[**Last Name (NamePattern4) 2138**]p Instructions:
[**Hospital Ward Name 121**] 6 in 2 weeks for wound check
Dr. [**Last Name (STitle) 17321**] 1-2 weeks. An appt. has been made for you on [**3-2**]
at 9:40 AM.
Dr. [**First Name (STitle) 1557**] 2-3 weeks
Dr. [**Last Name (Prefixes) **] 4 weeks
Completed by:[**2111-2-21**]
|
[
"4241",
"53081"
] |
Admission Date: [**2142-6-5**] Discharge Date: [**2142-6-9**]
Date of Birth: [**2083-11-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6565**]
Chief Complaint:
hypotension, anemia.
Major Surgical or Invasive Procedure:
EGD [**6-7**], colonoscopy [**6-8**].
History of Present Illness:
58 year old man with widely metastic prostate cancer (calverium,
spine, ribs, pelvis, and proximal humeri and femurs) presented
with profound weakness, n/v/d after initiating chemotherapy for
prostate cancer one week ago. He was admitted to the ICU with
hct 16 (baseline 25). He notes 1 week PTA initiating taxotere.
Additionally in that week he had difficulty with ambulation and
a fall and difficulty getting up. He notes urinary incontinence
that he says is due to inability to get to the bathroom but also
diarrhea with incontinence. This appears relatively new for him
but he notes he is able to control his sphincter function and
incontinence is in the setting of decreased ability to ambulate.
He had notes diarrhea that is watery with with brown/black
specks in that look like 'licorice' but denies BRBPR. He notes
increased productive cough (yellow sputum) for 3+ days PTA which
is not normal per him, but denies episodes of coughing or
choking on foods.
.
In the ED, patient initially had Temp 99.4, SBP in the 60s,
which improved to 90s with 3L NS, which is according to
oncologist at his baseline. He was also noted to have a hct of
16 and ANC of roughhly 1000. He received vancomycin in the ED.
He was tranferred to the ICU where he received 2 uPRBC's and was
continued on vanco/zosyn for pneumonia (by CT scan). Hct
improved to 28.2.
.
He denies fevers, chills (but is always cold), head ache,
abdominal pain, nausea, vomitting, or rashes. He states today he
feels much better than he has with much improved pain.
Past Medical History:
Oncologic history:
-presented [**12-19**] with diffuse bony pain (cervical, lumbar, lower
exremity) and weight loss (25-30 lbs). CT--diffuse mottled
appearance of the bones concerning for diffuse metastases, C6
and C7 spinous process fx. PSA = 30.4.
-Prostate biopsy=[**Doctor Last Name **] 5+4 prostatic adenocarcinoma
-Bone marrow biopsy=metastatic poorly differentiated carcinoma
associated with extensive fibrosis.
-s/p orchiectomy
-[**10-20**] started on ketoconazole/hydrocortisone, ordered stopped
[**3-21**] as disease progressive (but appears from outpatient
medication list that he continued taking it).
-[**2142-5-10**]: Symptoms from disease progression: worsening bilateral
pelvic bone pain and left shoulder pain.
-[**2142-5-29**]: palliative chemotherapy with taxotere/prednisone (but
appears that he has not had any prednisone as an outpatient).
.
PMH:
1. Chronic pancreatitis.
2. Malnutrition.
3. Anemia.
4. s/p abdominal gun wound many years prior with surgical
repair.
Social History:
Lives in [**Hospital3 **] vs. NH-[**Street Address(1) **]
Family History:
Unknown.
Physical Exam:
Vitals: T 98.6, P 101, BP 93/58, RR 16, O2 sat 100% on 2L
Gen: Cachectic, comfortable, speaking slowly in full sentences
LN:
HEENT: MMM, PERRL, EOMI
CV: RRR, no m/r/g
Chest: coarse crackles on right posteriorly
Abd: soft, nt, +bs
Ext: no c/c/e
Neuro: grossly intact, AAOx3
Guiac +
Pertinent Results:
Admission labs:
139 109 25
------------<100
4.5 20 1.0
estGFR: >75 (click for details)
Ca: 7.4 Mg: 1.4 P: 2.5
.
PT: 15.1 PTT: 30.8 INR: 1.4
.
CK: 28 MB: Notdone Trop-T: <0.01
Ca: 8.2 Mg: 1.4 P: 2.5
ALT: 12 AP: 155 Tbili: 0.8 Alb: 2.5
AST: 20 LDH: 236
[**Doctor First Name **]: 27 Lip: 12
Iron: 19
calTIBC: 90
Hapto: 473
Ferritn: >[**2135**]
TRF: 69
.
5.3
2.4>---<444
16.4---------->improved to 27.8 after 2 uPRBC's and remained
stable
N:25 Band:16 L:45 M:8 E:1 Bas:0 Atyps: 4 Metas: 1 Nrbc: 9
Neuts: TOXIC GRANULATIONS
Hypochr: 1+ Anisocy: 1+ Poiklo: OCCASIONAL Macrocy: 2+ Polychr:
OCCASIONAL Acantho: OCCASIONAL
Ret-Aut: 0.9
Lactate:1.3
.
Micro:
UA: negative, legionella antigen negative
Blood Cultures: No Growth
C. diff toxin A negative x2
.
Imaging:
Imaging:
CXR [**6-5**]:
1) Increased opacity in the right lower lobe is consistent with
a pneumonic consolidation.
2) Diffuse sclerotic osseous metastasis.
.
Abd Film [**6-5**]: 1) Nonspecific prominent loop of small bowel is
noted, which is likely unchanged in configuration in comparison
to the prior study. No other dilated loops of bowel.
2) Diffuse osseous sclerotic metastases.
3) Coarse calcification in the epigastric region from chronic
pancreatitis
.
Bone scan: Widespread metastatic bony disease.
.
CT Abd [**5-16**]:
1. Scattered small diffuse retroperitoneal adenopathy and right
iliac adenopathy. No regions meet criteria to be considered
target lesions.
2. Diffuse bony metastatic disease primarily sclerotic in
origin. However, with a single lytic area within the right iliac
bone andthat within the left iliac bone showing extension into
the adjacent musculature.
3. Findings consistent with chronic pancreatitis and a probable
simple pancreatic pseudocyst involving the pancreatic head.
Attention to this area on followup to ensure that this cyst
which appears simple, remains stable.
.
CXR [**2142-6-6**]: Multilobar pneumonia in the right lower lung has
improved since [**6-5**]. Left lung grossly clear. Heart size
normal. Pleural effusion if any is minimal, on the right.
Extensive blastic metastatic prostate carcinoma is seen in the
chest cage.
Brief Hospital Course:
A/P: 58 yo man with diffusely metastatic prostate cancer
presenting with anemia, hypotension, and pneumonia.
.
1 Hypotension: Resolved. Likely secondary to hypovolemia with
acute anemia, improved with IVF/transfussion, though in clinic
notes documented baseline 83-116 SBP. Not likely to be adrenal
insufficiency given response to treatment. BP remained stable
after initial volume resuscitation SBP: 95-120.
.
2 Anemia: Megaloblastic. Not clearly related to recent chemo,
hemolysis labs negative (high hapto, LDH normal, t.bili normal).
Retic inappropriately low, not surprising given his known
fibrosis of bone marrow with metastatic prostate CA. Iron
studies suggest AOCD, vitamin B12/folate replete. Stopped iron
supplement. Coags mildly elevated PT/INR. H/O melena and guaiac
positive in the icu (despite being negative in ED) suggests GIB
contributing to acute change. If on prednisone as outpatient
(unclear) could predispose him to GIB. Had negative EGD [**6-7**],
negative colonoscopy [**6-8**], hct stable since admit transfussion.
.
3 Pneumonia: CXR consistent with pneumonia, likely aspiration
given distribution but as living in long-term care facility
warrants treatment as HAP. Not currently neutropenic. Speech and
swallow cleared him (no observed aspiration risk). Urine
legionella ag negative. He was transitioned to levofloxacin for
po treatment and discharged to complete a 10 day course.
.
4 Metastatic Prostate cancer: s/p taxotere recently, held
prednisone given potential GIB but restarted [**6-8**] since hct
stable, continue morphine sulfate slow release and vicodin prn
for pain as outpatient pain regimen. Further treatment as an
outpatient. Will continue on prednisone 5mg [**Hospital1 **].
.
5 Diarrhea: Unclear etiology, may be related to GIB (blood is
cathartic in GI tract,) c.diff unlikely negative x2. Improved
during his admission.
.
6 Oropharyngeal [**Female First Name (un) **]: Noted on exam, improved with nystatin
swish and swallow qid.
.
7 Proph: [**Hospital1 **] pantoprazole, bowel regimen-held for diarrhea,
heparin sc tid.
.
8 Code status: DNR/DNI per discussion with patient-of note pcp
documents this as not c/w previously stated wishes, but verified
DNR/DNI on [**2142-6-9**].
Medications on Admission:
Iron sulfate 325 mg p.o. daily
folic acid 1 mg p.o. daily
multivitamin one tablet p.o. daily
thiamine 100 mg p.o. daily
MS contin 30 mg p.o. b.i.d.
nicotine 11 mg patch daily
colace 100 mg p.o. b.i.d.
ensure as needed,
prilosec 20 mg p.o. b.i.d.
Genasyme 80 mg p.o. b.i.d.
Vicodin as needed for pain.
Prednisone 5 mg **not sure if patient is taking, he can not
recall, can not name his pharmacy though notes it is [**Street Address(1) 69238**]
Discharge Medications:
1. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO BID (2 times a day).
8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
9. Levofloxacin 250 mg Tablet Sig: Five (5) Tablet PO Q24H
(every 24 hours) for 5 days: starting [**2142-6-10**].
10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Manor
Discharge Diagnosis:
Metastatic prostate cancer, anemia, pneumonia.
.
Chronic pancreatitis.
Discharge Condition:
Stable.
Discharge Instructions:
Please take all medications as prescribed. Please keep all
follow-up appointments. Please notify your primary care doctor
or Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] if you experience fevers, chills, nausea,
vomitting, worsening cough, shortness of breath, chest pain,
black or tarry stools, dizziness, lightheadedness or any
symptoms that concern you.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] on [**2142-6-21**]
at 9:00am. Please call [**Telephone/Fax (1) 22**] if questions.
[**First Name4 (NamePattern1) 2946**] [**Last Name (NamePattern1) **] MD [**MD Number(1) 3218**]
|
[
"5070"
] |
Unit No: [**Numeric Identifier 67325**]
Admission Date: [**2150-6-20**]
Discharge Date: [**2150-6-25**]
Date of Birth: [**2150-6-20**]
Sex: F
Service: NB
HISTORY: Baby girl [**Known lastname **]-[**Known lastname 1968**] is a term female born to a 30-
year-old G1, P0, now 1 mother.
Prenatal screens - blood type O positive, antibody screen
negative, hepatitis B surface antigen negative, RPR
nonreactive, rubella immune, GBS negative. Pregnancy was
uncomplicated. No history of maternal HSV infection or any
medications. Delivery was a spontaneous vaginal delivery with
Apgars of 8 and 9. Rupture of membranes 4 hours prior to
delivery. No maternal fever noted. Epidural anesthesia.
The infant was admitted to the newborn nursery and was doing
well breast feeding. No formula documented as being given.
The baby had been afebrile with normal vital signs. At
approximately 12 hours of life the baby was noted to have
significant episode of apnea with cyanosis requiring
significant stimulation and blow-by oxygen. No abnormal
movements were described. Two minor episodes were reported by
nursing. On admission to the newborn intensive care unit the
baby had another episode witnessed by physician and nursing.
During this episode the baby had diffuse hypotonia and with
extension of the upper and lower extremities and pursing of
her lips. No clonic movements were noted. No eye deviation
was noted.
PHYSICAL EXAMINATION: Weight 3.4 kg, length 51 cm, head
circumference 34 cm. Anterior fontanel soft and flat. Mild
molding. Palate intact. Eyes with red reflex bilaterally.
Breath sounds clear and equal. No retractions.
CARDIOVASCULAR: S1 and S2 normal. No murmur. Abdomen soft
with no organomegaly. Normal external female genitalia.
Mongolian spot in the sacral region. Overall tone in lower
extremities mildly increased. Head control fair, suck reflex
poor. Normal gag reflex. Truncal tone within normal limits.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Infant
briefly was on nasal cannula on admission to the newborn
intensive care unit. Arterial blood gases on admission had a
pH of 7.42, PCO2 of 37, PO2 of 67, bicarbonate 25 and a
deficit of 0. The infant weaned quickly back to room air and
she has been stable in room air since that time. Last
documented episode of desaturations was on [**6-20**] at 6 p.m.
CARDIOVASCULAR: No issues.
FLUIDS, ELECTROLYTES AND NUTRITION: The infant was initially
started on 60 cc per kg per day of D10W. Enteral feedings
were started on day of life 1. The infant has currently ad
lib breast feeding with supplement of Enfamil 20 calorie
taking in adequate amounts. Her discharge weight is 3345g.
GASTROINTESTINAL: Peak bilirubin was 13.7/0.4. The infant
has not required any interventions.
HEMATOLOGY: Hematocrit on admission was57.5. She did not
require any blood transfusions.
INFECTIOUS DISEASE: Due to the severity of these spells at 12
hours of life and concern for neurologic involvment, a CBC and
blood culture obtained on admission. Lumbar puncture was also
performed. All lab results were normal. The infant was started on
ampicillin, gentamycin and acyclovir. Acyclovir was discontinued
on [**6-24**] with an HSV PCR as negative. Ampicillin and gentamycin
were discontinued at 48 hours with negative blood culture.
NEUROLOGIC: Lumbar puncture was within normal limits. CT scan
was read as normal. EEG was normal with no seizure activity.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 48342**] evaluated the infant and actually signed off
on the infant as he felt there was no neurologic component to
the desaturations. LFTs were performed and were completely
normal. A metabolic screen was normal.The infant has been
appropriate for gestational age with no further episodes since
[**2150-6-20**].
SENSORY: Hearing screen was performed with automated auditory
brain stem responses and passed bilaterally.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 449**]. Telephone
No.: [**Telephone/Fax (1) 62659**].
CARE RECOMMENDATIONS:
1. Continue ad lib breast feeding with Enfamil 20 calorie
supplementation.
2. Medications: Not applicable.
3. Car seat position screening: Not applicable.
4. Immunizations received: The infant received Hepatitis B
vaccine on [**2150-6-24**].
DISCHARGE DIAGNOSES:
1. Cyanotic episode in newborn nursery.
2. Rule out seizure activity.
[**First Name11 (Name Pattern1) 3692**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 27992**], MD [**MD Number(2) 65951**]
Dictated By:[**Last Name (NamePattern1) 58682**]
MEDQUIST36
D: [**2150-6-24**] 20:59:34
T: [**2150-6-25**] 01:22:30
Job#: [**Job Number 67326**]
|
[
"V053",
"V290"
] |
Admission Date: [**2171-12-15**] Discharge Date: [**2171-12-18**]
Date of Birth: [**2123-8-28**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10488**]
Chief Complaint:
Acetaminophen/Diphenhydramine Overdose
Major Surgical or Invasive Procedure:
Intubation/Extubation
History of Present Illness:
Ms. [**Known lastname 4318**] is a 48 year-old woman with no known medical
history. This history is deciphered from ED notes and the report
of her [**Known lastname **]. Ms. [**Known lastname 4318**] has no history of depression but had
been recently out of work and in relationship problems and was
noted to be more down than usual. Today around 1500, she was
found by a passerby wandering around outside her car in an empty
area. She had a bottle of tylenol/diphenhydramine 100 tabs of
500 mg each. She was also found with detergent bottles and
alcohol bottles by report, although her [**Known lastname **] deny this. There
was a suicide note stating that she was overwhelmed with
financial problems and felt like a disappointment to her friends
and family.
.
At [**Hospital6 33**], the patient was unresponsive. Urine tox
was positive for tricyclics and cocaine. Serum acetaminophen
level was 348. Serum ethanol was negative. She was intubated
with etomindate and succinylcholine and started on fentanyl and
midazolam. She was also paralized with rocuronium. NG lavage
with administration of activated charcoal was performed. NAC and
bicarbonate drips were started (unclear why bicarb drip
started). She was trasnferred to [**Hospital1 18**].
.
At [**Hospital1 18**],initial VS T 100.4, HR 111, BP 142/98, RR 14, O2 100%
RA. Urine tox was positive for benzos. Serum acetaminophen level
was 155 at [**2161**], approximately 5 hours after the ingestion. EKG
showed a [**Year (4 digits) 15015**] QRS complex. Bicarbonate drip was stopped. She
was transferred to the MICU. VS prior to transfer HR 111,
142/78, 14, 100% on 400/14, PEEP 5, FiO2 .3.
Past Medical History:
per [**Year (4 digits) **], thyroid problems (unknown hypo- or hyper)
No history of psychiatric problems.
Social History:
She lives with her boyfriend and works as an iron worker but has
been out of work recently. There have also been relationship
problems with her boyfriend. [**Name (NI) **] [**Name2 (NI) **] adamently deny that she
ever uses alcohol or any illicit drugs. She is a "heavy smoker."
Family History:
unknown
Physical Exam:
VS: HR 104, BP 147/86,
GEN: intubated, sedated, moving all extremities, not arousable
to voice or sternal rub
HEENT: pupils pinpoint
RESP: clear anteriorly
CV: regular, no murmru
ABD: soft, nontender
EXT: warm, no edema, R hand with [**Doctor Last Name **] erythematous rash with
scattered petechiae around the acetylcysteine infusion site
SKIN: no rashes/no jaundice/no splinters
Pertinent Results:
[**2171-12-15**] 08:14PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2171-12-15**] 08:14PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2171-12-15**] 08:14PM FIBRINOGE-198
[**2171-12-15**] 08:14PM PLT COUNT-195
[**2171-12-15**] 08:14PM PT-13.1 PTT-21.7* INR(PT)-1.1
[**2171-12-15**] 08:14PM WBC-9.5 RBC-3.96* HGB-12.3 HCT-35.1* MCV-89
MCH-31.0 MCHC-35.0 RDW-12.8
[**2171-12-15**] 08:14PM freeCa-0.99*
[**2171-12-15**] 08:14PM HGB-12.2 calcHCT-37 O2 SAT-97 CARBOXYHB-2 MET
HGB-0
[**2171-12-15**] 08:14PM GLUCOSE-129* LACTATE-0.9 NA+-141 K+-4.2
CL--107 TCO2-24
[**2171-12-15**] 08:14PM PH-7.38 COMMENTS-GREEN TOP
[**2171-12-15**] 08:14PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2171-12-15**] 08:14PM URINE UCG-NEG
[**2171-12-15**] 08:14PM URINE HOURS-RANDOM
[**2171-12-15**] 08:14PM ASA-NEG ETHANOL-NEG ACETMNPHN-155*
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2171-12-15**] 08:14PM TSH-<0.02*
[**2171-12-15**] 08:14PM CALCIUM-7.1* PHOSPHATE-3.6 MAGNESIUM-1.7
[**2171-12-15**] 08:14PM LIPASE-15
[**2171-12-15**] 08:14PM ALT(SGPT)-15 AST(SGOT)-18 ALK PHOS-63
AMYLASE-36 TOT BILI-0.3
[**2171-12-15**] 08:14PM estGFR-Using this
Brief Hospital Course:
A/P: A 48 year-old woman presents with acetaminophen and
possible other overdose, intubated
.
# Overdose: Primary concern was acetaminophen. Level 155 ~5
hours after the presumed time of ingestion. Assuming the 1500
timing of the ingestion is correct, she is on the borderline of
possible hepato-toxicity. She received IV acetylcysteine load
followed by 20 hour drip. LFTs and acetaminophen levels were
trended q8h until acetaminophen level undetectable. LFTs
remained normal and INR peaked at 1.2.
With regard to other ingestions, she would have theoretically
received 2500 mg of diphenhydramine. This likely accounted for
positive TCA screen. QRS was [**Last Name (LF) 15015**], [**First Name3 (LF) **] the bicarbonate drip
was stopped in the ED. QRS duration was monitorred q1h for the
first twelve hours and remained <100 ms .
.
The patient was easily extubated several hours after admission
to the ICU. Psychiatry was consulted the following day. The
patient was transferred to the floor following extubation. On
the floor she had tachycardia which was improved with fluid
boluses. She had a fever on transfer however, this resolved
after getting a fluid bolus. Given that the patient was
tachycardic, and had episodes of temperature above 100, and a
history of non-compliance with hyperthyroid medication, the
patient had an endocrine consult placed. She had no sequelae of
acetaminophen and diphenhydramine overdose with normal exam and
flat LFTS throughout admission.
.
# Suicidal Ideation:
The overdose clearly a suicide attempt as the patient admits as
well as evidenced by the suicide note that she left. Psychiatry
saw the patient and recommended that she be admitted for
inpatient psychiatry . She was placed on a 1:1 sitter and bed
search began. There were no medical contraindications to being
admitted to an inpatient psychiatric facility.
.
# Thyroid: Upon extubation, the patient stated that she had
previously been on methimazole and that she had stopped this on
her own for unclear reasons. TSH was checked as was <.02. Given
that on the floor she had a elevated temperature as well as
tachycardia she had an endocrine consult placed. Endocrine
recommended obtaining full thyroid panel which was obtained. The
panel came back unremarkable except for the antiTPO which had
not resulted. Endocrine team w/ attending saw patient determined
that this was subclinical hyperthyroidism and that the patient
was certainly not in thyroid storm. The endocrine team did not
recommend starting any medication and only warranted an
outpatient radioiodine uptake test.
.
Medications on Admission:
None
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
acetaminophen/diphenhydramine overdose
suicidal ideation
urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen and evaluated for your tylenol pm overdose as well
as your suicide attempt. For your tylenol pm overdose you were
given a medication which prevented any damage to your liver. You
remained stable throughout your hospital admission. The
psychiatrist saw you and recommended that you be admitted to an
inpatient psychiatric facilty for further care.
Call your doctor or return to the Emergency Department right
away if any of the following problems develop:
* You feel unsafe.
* You done something to harm yourself or someone else, or are
afraid you might.
* You develop new or different symptoms that worry you.
You were seen by the endocrine doctor and found to not need any
further intervention for your hyperthyroidism in the intpatient.
PLEASE FOLLOW UP WITH YOUR PRIMARY CARE DOCTOR FOR A RADIOACTIVE
IODINE UPTAKE TEST.
Please also follow up with your primary care doctor for your
urinary tract infection. You were given an antibiotic for it to
continue for 7 days.
Followup Instructions:
Please follow up with your primary care doctor in [**1-27**] days after
discharge from your psychiatric facility.
PLEASE WHEN YOU FOLLOW UP WITH YOUR PRIMARY CARE DOCTOR, HAVE
LIVER FUNCTION TESTS DRAWN.
Please follow up with your outpatient psychiatric provider [**Last Name (NamePattern4) **]
[**1-27**] days after discharge from your psychiatric facility.
|
[
"5990"
] |
Admission Date: [**2204-3-28**] Discharge Date: [**2204-4-3**]
Date of Birth: [**2136-12-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**2204-3-28**]: Placement of percutaneous cholecystostomy tube.
History of Present Illness:
Patient is a 67-years-old male was presented in [**Hospital1 **] [**Location (un) 620**] with
c/c abdominal pain on [**2204-3-28**]. CT abdomen revealed likely
cholecystitis vs. cholangitis. Patient was started on
Ceftriaxone and Flagyl and was transferred to [**Hospital1 18**] for further
w/u and management.
Past Medical History:
1. Hypertension
2. Hypercholesterolemia
3. Diabetes
4. Peripheral vascular disease
5. CVA with R hemiparesis and right facial palsy
6. Anemia
7. BPH
8. Hypomagnesemia
9. Right femur fracture
10. Depression
Social History:
Resident in skilled nursing facility. Toxic habits not known.
Family History:
Unknown
Physical Exam:
On Discharge:
VS: T 97.4, HR 74, BP 124/66, RR 18, O2 Sat 94%
GEN: Awake and alert, Confused, NAD
HEENT: PERRL, Right gaze preference, right facial palsy
HEART: RRR, no m/r/g
LUNGS: Coarse b/l
ABD: Soft, nontender, right PCT w/dressing c/d/i
EXT: Right hemiparesis, left - normal muscle tone, follows all
commands.
Pertinent Results:
[**2204-3-28**] 06:43AM GLUCOSE-264* LACTATE-3.3* NA+-135 K+-4.5
CL--93* TCO2-26
[**2204-3-28**] 06:30AM GLUCOSE-263* UREA N-22* CREAT-0.8 SODIUM-133
POTASSIUM-4.4 CHLORIDE-93* TOTAL CO2-27 ANION GAP-17
[**2204-3-28**] 06:30AM ALT(SGPT)-76* AST(SGOT)-94* CK(CPK)-43* ALK
PHOS-134* TOT BILI-1.8*
[**2204-3-28**] 06:30AM LIPASE-16
[**2204-3-28**] 06:30AM WBC-28.2*# RBC-4.52*# HGB-13.9*# HCT-40.0#
MCV-88 MCH-30.6 MCHC-34.7 RDW-13.3
[**2204-3-28**] 06:30AM NEUTS-90.3* LYMPHS-4.1* MONOS-5.4 EOS-0.1
BASOS-0.2
[**2204-3-28**] 06:30AM PLT COUNT-316
[**2204-3-28**] 06:30AM PT-15.1* PTT-26.9 INR(PT)-1.3*
[**2204-3-28**] 07:15AM URINE BLOOD-SM NITRITE-NEG PROTEIN-75
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-8* PH-7.0 LEUK-MOD
[**2204-3-28**] 8:41 am MRSA SCREEN Source: Nasal swab.
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2204-3-28**] 7:15 am URINE
URINE CULTURE (Final [**2204-3-29**]): YEAST. >100,000
ORGANISMS/ML..
[**2204-3-30**] BEDSIDE SWALLOWING EVALUATION:
RECOMMENDATIONS:
1. PO diet: ground solids, nectar thick liquids
2. Meds crushed in puree
3. TID oral care
4. Assist with meals as needed to assist with self-feeding and
maintain standard aspiration precautions.
[**2204-4-2**] CHOLANGIOGRAM:
IMPRESSION: Persistent obstruction at the level of the cystic
duct.
Indwelling cholecystostomy tube in adequate position.
Cholelithiasis.
[**2204-3-30**] 06:00AM BLOOD ALT-24 AST-28 AlkPhos-93 TotBili-0.5
[**2204-3-30**] 06:00AM BLOOD WBC-10.1# RBC-2.99* Hgb-9.2* Hct-26.6*
MCV-89 MCH-30.7 MCHC-34.5 RDW-13.3 Plt Ct-215
[**2204-3-30**] 06:00AM BLOOD Glucose-81 UreaN-33* Creat-0.6 Na-136
K-3.6 Cl-102 HCO3-26 AnGap-12
Brief Hospital Course:
The patient was admitted in SICU to the General Surgical Service
for evaluation of the aforementioned problem. On [**2204-3-28**], the
patient underwent IR guided placement of cholecystostomy tube
with drainage catheter, which went well without complication
(reader referred to the Procedure Note for details). Patient was
continue on IV antibiotics with Flagyl, Levofloxacin and
Fluconazole. Patient was continue to have IV fluid for hydration
with boluses for low urine output and tachycardia. ON [**3-29**] NG
tube was clamped and patient was advanced to clears with PO home
meds.The patient was hemodynamically stable and was transferred
on the floor. On [**2204-3-30**] patient was neurologically stable,
afebrile with stable vital signs. Swallowing evaluation was
performed and patient was advanced to his baseline of soft
solids and nectar thick liquids with meds crushed in puree once
he is reunited with his dentures. Patient was ordered to have
diagnostic cholangiogram. On [**3-31**] and [**4-1**] patient was afebrile,
with stable vital signs, neurologically stable. On [**2204-4-2**]
patient underwent diagnostic cholangiogram, which revealed
continued cystic duct obstruction, adequate position of the
cholecystostomy tube within the gallbladder, and Cholelithiasis.
On [**2204-4-3**] patient was discharged back in Nursing Home with
instruction to continue antibiotics for another 3 days. Patient
will have a follow up appointment with Dr. [**Last Name (STitle) **] in one month
after discharge.
.
During this hospitalization, patient was neurologically on his
baseline. He is awake and alert, baseline confused. He continue
to have right sided hemiparesis s/t CVA, he follows simple
commands on left side. The patient received subcutaneous
heparin and venodyne boots were used during this stay. The
patient's blood sugar was monitored regularly throughout the
stay; sliding scale insulin was administered when indicated.
Labwork was routinely followed; electrolytes were repleted when
indicated.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a soft
solids diet with nectar thick liquids, voiding without
assistance, and pain was well controlled. The patient was
discharged in his skilled nursing facility with detailed
discharge and follow-up instructions.
Medications on Admission:
1. Novolin (80U qam, 22U qpm, novolin SS)
2. Norvasc 5 mg PO qday
3. Lisinopril 10 mg PO qday
4. Metoprolol 25 mg Po bid
5. ASA 81 mg PO qday
6. Seroquel 25 mg PO qhs and 25 mg PO prn
7. Depakoate 500 mg PO tid
8. Cymbalta 60 mg PO qday
9. Flomax 0.4 mg PO daily
10. Trazadone 25 mg PO prn
11. Percocet 5/325 mg PO prn
12. Combivent nebs prn
13. Senna 2 tabs PO qday
14. Colace 100 mg PO bid
15. MOM 30 ml PO prn
16. Bisacody l0 mg PR prn
17. Fleet enema prn
18. Tylenol prn, MVI
19. MVI qday
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Duloxetine 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for agitation.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every four (4) hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-14**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
11. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for agitation.
13. Divalproex 125 mg Capsule, Sprinkle Sig: Four (4) Capsule,
Sprinkle PO TID (3 times a day).
14. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a
day for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
15. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for
3 days.
Disp:*3 Tablet(s)* Refills:*0*
16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for groin irritation.
17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for constipation.
18. Novolin N 100 unit/mL Suspension Sig: Eighty (80) units
units Subcutaneous qam and 22 units SC qpm.
19. Novolin R 100 unit/mL Solution Sig: [**3-7**] sliding scale units
Injection sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
1. Acute cholecystitis
2. Vascular dementia
3. Right hemiparesis
Discharge Condition:
Mental Status: Confused - always
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair
Discharge Instructions:
General Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed. Please get plenty of rest,
continue to ambulate several times per day, and drink adequate
amounts of fluids. Avoid lifting weights greater than [**5-21**] lbs
until you follow-up with your surgeon, who will instruct you
further regarding activity restrictions. Avoid driving or
operating heavy machinery while taking pain medications. Please
follow-up with your surgeon and Primary Care Provider (PCP) as
advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
1.Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2204-5-11**] 10:00. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**]
.
Please call ([**Telephone/Fax (1) 56735**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 31**] in [**2-15**] weeks.
Completed by:[**2204-4-3**]
|
[
"4019",
"2720",
"25000",
"2859"
] |
Admission Date: [**2115-2-13**] Discharge Date: [**2115-4-6**]
Date of Birth: [**2079-6-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
Abdominal pain, distention
Major Surgical or Invasive Procedure:
Diagnostic Paracentesis x 3
PICC line placement x 2
Endotracheal Intubation x 3
Arterial Line Placement x 2
Left IJ CVL
History of Present Illness:
35 yo M with cerebral palsy who initially presented [**2115-2-13**] with
abdominal pain and distention to an OSH. CT scan was performed
and was reported as diffuse bowel edema, gastric varices,
ascites and a pancreatic cyst. He reportedly had no associated
nausea, vomiting, diarrhea, hematemesis, hematochezia, jaundice,
fevers or dysuria. Also reported no recent weight loss, no
NSAIDs or ASA use. In ED, his initial vitals temp 98.0 HR 100 BP
83/59 RR 20. He then received Unasyn at the OSH. Foley placed,
recieved IVF and was transferred to [**Hospital1 18**]. Patient was
non-verbal, in distress.
Per family, patient had multiple admissions prior for
constipation, with a recent drainage of a pancreatic cyst this
past year in [**Hospital3 **]. He has a bowel movement everyday
except on the day of presentation to the OSH. He tolerated PO
and was at his baseline the night of his presentation. His
abdomen was distended and painful to palpation according to his
mother, which is why she brought her son to the OSH.
Upon transferred to [**Hospital1 18**] [**2-13**] and admitted to the SICU team
given concern for an acute surgical abdomen. Diagnostic
paracentesis ([**2-13**]) with WBC [**Numeric Identifier **] (no growth so thought to be
[**1-15**] inflammatory state), Lipase 216, Amylase 141. He was
started on Vanco/Zosyn/Flagyl for suspected peritonitis and
ischemic bowel with translocation. He was then intubated [**2115-2-14**]
(in the ED) for respiratory failure. A left subclavian line was
placed on [**2-14**]. He was then given Phenytoin but this was
transitioned to Keppra the same day. On [**2-15**] Vitamin K 1mg was
infused. TPN started [**2115-2-15**]. He was continued on maintenance
IVF with intermittent bolus but on [**2-16**] was given Lasix. On [**2-16**]
he was started on Heparin gtt for SMV thrombus. Did have
diarrhea, but improving over the course of admission. [**2115-2-16**]
with 3L therapeutic / diagnostic paracentesis (negative culture
to date, WBC 1390). Concerning his respiratory status, he was
extubated [**2-17**] (s/p 4 days of mechanical ventilation) and
re-intubated [**2-18**] given increased secretions and concern that he
was unable to protect his airway. On [**2-18**] Warfarin was started
and Flagyl was discontinued. On [**2-19**] Tobramycin was added for
suspected untreated infection given lower blood pressures. Upon
transfer there is no positive culture data. Patient has been
febrile > 100.5 on [**2-10**] and [**2-19**] but without leukocytosis.
Also with persisent tachycardia > 100 bpm except for [**2-16**] and
[**2-20**]. CTA Abdomen / pelvis with SMV thrombus, Vascular surgery
consulted and thought it was likely a chronic issue given degree
of collaterals and probably due to chronic pancreatic
inflammation with associated vascular congestion and slowing.
Given no acute surgical issues, patient was transferred to the
Medical ICU team on [**2115-2-20**]. Upon initial evaluation, family at
bedside confirms that he felt unwell for about one week prior to
admission. He is nonverbal at baseline, but will push your hand
away if you push his abdomen and he's in pain. Otherwise, no
localizing symptoms.
Past Medical History:
Cerebral Palsy
Seizure disorder
Chronic anemia - Hct 35
GIB in [**2110**]
h/o liver cyst drainage ([**2113**], [**Hospital3 7362**])
H/o Laproscopic cholecystectomy
H/o pancreatic cyst drainage with chronic pancreatitis
Social History:
Lives at home with family, goes to school 5 days a week, no
recent travels, no smoke/drink/IVDU.
Family History:
NC, Maternal grandmother had DM, paternal grandfather had HTN,
parents healthy.
Physical Exam:
Upon transfer to MICU
98.3, 79, 100/70, 22, 100% SIMV [**9-20**], 12, TV 300, 50% CVP 13
Gen: Thin, no apparent distress but slight tearing in left eye;
alert
HEENT: Sclera anicteric, eyes sunken, MMM, ET in place
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally anteriorly, no wheezes,
rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, flat, patient pushes hand away with palpation in
LUQ/LLQ, bowel sounds present, no guarding, unable to assess
rebound tenderness
GU: Foley in place
Ext: warm, very thin, cannot palpate radial pulses or DP b/l, no
cyanosis or edema
Pertinent Results:
ADMISSION LABS:
[**2115-2-13**] 12:25PM BLOOD WBC-8.8 RBC-3.91* Hgb-10.7* Hct-34.6*
MCV-89 MCH-27.4 MCHC-31.0 RDW-20.8* Plt Ct-202
[**2115-2-13**] 12:25PM BLOOD Neuts-83* Bands-11* Lymphs-4* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2115-2-13**] 12:25PM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-NORMAL
Macrocy-1+ Microcy-1+ Polychr-NORMAL
[**2115-2-13**] 12:25PM BLOOD Plt Smr-NORMAL Plt Ct-202
[**2115-2-13**] 12:25PM BLOOD Glucose-92 UreaN-13 Creat-0.5 Na-142
K-4.4 Cl-108 HCO3-25 AnGap-13
[**2115-2-13**] 12:25PM BLOOD ALT-15 AST-20 AlkPhos-146* TotBili-0.1
[**2115-2-13**] 12:25PM BLOOD Albumin-2.1*
[**2115-2-19**] 07:59PM BLOOD Vanco-6.1*
[**2115-2-20**] 10:05AM BLOOD Tobra-0.7*
[**2115-2-21**] 06:00AM BLOOD Vanco-72.3*
-----------------
DISCHARGE LABS:
-----------------
STUDIES:
[**2115-2-13**] CXR: 1. Low lung volumes. No focal consolidation. 2.
Small bowel wall thickening and dilation, better evaluated on
the outside hospital CT.
.
[**2115-2-15**] KUB: IMPRESSION: No evidence of free air. There is a
relative paucity of bowel gas on this study; distended loops of
fluid-containing small bowel cannot be excluded.
.
[**2115-2-16**] CTAP: IMPRESSION: 1. Diffusely abnormal gastrointestinal
tract with mucosal hyperenhancement and wall thickening. Given
the finding of SMV occlusion, findings are highly concerning for
venous congestion/ischemia. An element of shock bowel could also
be a possibility. 2. Hyperenhancement of the adrenal glands and
narrowed distal aorta, iliac and femoral vessels, suggesting
hypovolemia/shock. Correlate clinically. 3. Sequelae of chronic
pancreatitis with a rim-enhancing fluid collection in the region
of the pancreatic head, likely representing pseudocyst. This may
be the etiology of SMV thrombosis. 4. Diffusely abnormal hepatic
parenchyma, consistent with the history of hepatitis. Partially
occlusive right portal vein thrombus. 5. Small bilateral pleural
effusions, increased from the prior exam. Ground- glass and
nodular opacities at the lung bases suggesting infection.
.
[**2115-2-19**] TTE: Technically limited study; Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. The aortic valve
leaflets are moderately thickened. At least mild to moderate
aortic stenosis is present (but cannot be fully quantified). No
aortic regurgitation is seen. There is no pericardial effusion.
.
[**2115-2-26**] Renal US 1. Small size and echogenic appearance of the
kidneys consistent with chronic, diffuse parenchymal disease. No
hydronephrosis. 2. Ascites.
.
[**2115-3-6**] Abdomen US IMPRESSION: Small ascites. Again noted
probable pseudocyst in the midline and collateral vessels
related to the SMV thrombosis.
.
[**2115-3-7**]: KUB Multiple dilated loops of large and small bowel,
more prominent is colonic dilation. Findings are concerning for
large bowel obstruction.
.
[**2115-3-9**]: KUB Interval increase in gaseous distension of a
segment of colon in the lower abdomen. Appearance is
nonspecific, but distal colonic obstruction cannot be excluded
and further evaluation by CT should be considered.
.
[**2115-3-10**]: KUB There has been apparent placement of a rectal tube
(recommend clinical correlation with recent procedural history).
There has been decrease in degree of distention of a prominent
loop of bowel in the lower mid abdomen, likely representing
sigmoid colon, with decrease in maximal diameter from about 10
cm to 8.6 cm in transverse width. Other air- filled loops of
small and large bowel appear relatively similar to the recent
radiograph. By report, there is clinical concern for
perforation. Either an upright or left lateral decubitus
abdominal radiograph would be recommended to evaluate for free
intraperitoneal air. Alternatively, a CT could be performed.
.
[**2115-3-11**]: CT Abd/Pelvis
INDICATION: 35-year-old man with known microperforation,
small-bowel
obstruction and colonic dilatation. Increased abdominal
distention.
TECHNIQUE: CT imaging of the abdomen and pelvis was performed
following the administration of oral and intravenous contrast.
Multiplanar reconstructions were generated.
COMPARISON: Comparison is made to prior CT performed [**2115-2-24**].
FINDINGS:
CT ABDOMEN:
Small bilateral basal pleural effusions have decreased in size
in comparison to the prior CT. There has also been partial
resolution of atelectasis and consolidation in the basilar
segments of both lower lobes. A nasogastric tube is in situ with
tip in the gastric body. There is moderate gaseous distention of
the stomach. There is marked distention of the sigmoid colon
with gas and debris, although mural thickening is less prominent
than on CT performed [**2115-2-16**]. A rectal catheter is in situ. The
remainder of the colon is less distended than the sigmoid colon,
but also contains fluid and gas throughout. No discrete
transition point is identified within the large bowel. The small
bowel is not significantly dilated. No free fluid or gas is seen
within the abdomen or pelvis.
The patient is status post cholecystectomy. No focal parenchymal
abnormality is identified in the liver. The pancreas is atrophic
in appearance as on prior scan. Calcifications are again
identified at the pancreatic head. A 1.7 cm x 1.4 cm cystic
lesion at the pancreatic head seen on the prior CT is again
identified, but is of higher attenuation than on the previous
scan. A cortical cyst at the mid pole of the right kidney
measuring 1.4 cm x 1.2 cm is unchanged from prior study. No
other focal renal lesion is seen. The adrenal glands and spleen
are normal in appearance. A small amount of free fluid is seen
in the abdomen and pelvis, which has decreased in comparison to
the prior CT scan. Small bowel dilatation is less prominent than
on the prior scan.
There is occlusion of the superior mesenteric vein at the level
of the
pancreas (series 2, image 28), but the proximal portion of the
vein remains patent. Extensive collateral vessels are again
identified in the perigastric area. The portal vein and left and
right portal branches are patent.
CT PELVIS:
No pelvic lymphadenopathy is seen. The urinary bladder appears
unremarkable, but is pushed anteriorly by the distended rectum
and sigmoid colon. Marked degenerative changes are seen in the
thoracolumbar spine with scoliosis convex to right.
IMPRESSION:
1. Marked distention of the rectum and sigmoid colon with gas
and fluid. The distention is more marked than on the prior scan
[**2115-2-24**], but the degree of mural thickening in the sigmoid
colon has decreased in comparison to CT [**2115-2-16**]. A catheter is
in situ within the lumen of the distatl sigmoid colon. Mild
distention with gas and fluid in the remainder of the colon.
2. No free intraperitoneal gas is seen. Ascites has decreased in
volume in
comparison to the prior CT.
3. Occlusive thrombus is again identified in the distal portion
of the
superior mesenteric vein. The portal vein remains patent.
[**2115-3-12**]: Portable Abdomen
HISTORY: colonic distension with rectal tube
SUPINE ABDOMEN:
There is marked dilation of large bowel, with sigmoid colon
measuring up to 9.8 cm, overall unchanged when compared to prior
study. There is no free intraperitoneal air or pneumatosis.
Surgical clips are seen in the right upper quadrant. The bladder
is filled with contrast. The rectal tube is not seen on today's
study.
IMPRESSION:
Unchanged marked colonic/sigmoid dilation.
[**2115-3-13**]: Portable Abdomen
HISTORY: Vomiting.
COMPARISON: Multiple priors including [**2115-3-12**].
SUPINE AND UPRIGHT ABDOMEN:
Unchanged marked dilation of large bowel with sigmoid colon
measuring up to 10 cm in diameter, may represent chronic air
swallowing pattern. There is no free intraperitoneal air or
pneumatosis. Surgical clips are seen in the right upper
quadrant. Nasogastric tube is seen in appropriate position.
IMPRESSION: Unchanged marked large bowel dilation.
[**2115-3-13**]: CT Abd/Pelvis
CLINICAL INDICATION: History of SMV occlusion and large bowel
obstruction,
with worsening abdominal distention and new hypotension.
TECHNIQUE: MDCT of the abdomen and pelvis was performed
following the
uneventful administration of nonionic intravenous contrast and
oral contrast. Comparison exam is dated [**2115-3-11**].
FINDINGS: Limited images of the lung bases demonstrate small
left pleural
effusion, unchanged and trace right pleural fluid. There is
bibasilar
atelectasis, left greater than right.
A feeding tube is seen terminating in the third portion of the
duodenum.
Compared to the prior exam, there is increased abdominal
ascites, which is
slightly hyperdense, measuring 30 Hounsfield units in some
areas. There has been interval development of marked colonic
wall thickening involving the ascending colon, descending colon,
sigmoid and rectum. The transverse colon appears relatively
spared. There is an area of mass-like hyperdense
thickening of the descending/transverse colon junction (2:63).
Additionally, hyperdensity is seen tracking along the descending
colonic wall, likely representing hemorrhage. Compared to the
prior exam, there is decreased distention of the rectum and
sigmoid colon. A rectal tube is now in place. There is a new
hyperdense left retroperitoneal collection extending from just
inferior to the left kidney into the pelvis, interposed between
the rectum and bladder and displacing the bladder anteriorly and
inferiorly. There are a few foci of gas in the left rectus
muscle. Additionally, there is a focus of gas which appears to
be intraperitoneal (2:62), that was not clearly present on the
prior exam. It is not clear whether this is extraluminal or not.
There is no contrast extravasation. There are prominent small
bowel loops with diffuse distention, but no evidence of
transition point. The small bowel is
non-thickened. Again noted are numerous venous collaterals
related to known SMV occlusion. The portal vein again
reconstitutes and is patent, as is the splenic vein.
The pancreas is atrophic with multiple calcifications in the
region of the
head, consistent with chronic pancreatitis. The gallbladder is
surgically
absent. There is a right renal cyst. The left kidney, adrenal
glands and
spleen are unremarkable.
PELVIS: The bladder contains a Foley catheter with contrast and
foci of gas. There are no pathologically enlarged lymph nodes.
There is diffuse mild anasarca. Bone windows demonstrate
scoliosis and degenerative changes of the spine. There are no
focal suspicious lesions.
IMPRESSION:
1. Interval development of marked colonic thickening involving
the ascending colon, descending colon, sigmoid and rectum,
concerning for colitis, possiblby on the basis of venous
obstruction. There is hyperdense mass-like thickening at the
junction of the descending colon and transverse colon, which is
new from the prior exam and consistent with hemorrhage.
Hyperdensity is also seen along the descending colonic wall,
also likely representing hemorrhage. There is a focus of gas
which appears to be within the peritoneal cavity (2:62), not
present on the prior study. This is not clearly extraluminal and
no oral contrast extravasation is seen, although perforation
cannot be fully excluded.
2. Interval development of a large left retroperitoneal hematoma
extending in the pelvis.
3. Prominent small bowel distention diffusely, consistent with
ileus.
4. Increased abdominal ascites, slightly hyperdense, suggesting
a component of hemoperitoneum.
5. Numerous collateral vessels related to known SMV occlusion.
This appears stable from the prior exam, and the portal vein is
patent and reconstituted.
[**2115-3-15**]: PICC LINE PLACEMENT
INDICATION: IV access needed for IV access and fluids.
The procedure was explained to the patient. A timeout was
performed.
RADIOLOGIST: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] performed the procedure. Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) 4154**], the attending radiologist who was present and supervising
throughout.
TECHNIQUE: Using sterile technique and local anesthesia, the
left brachial
vein was punctured under direct ultrasound guidance using a
micropuncture set.Hard copies of ultrasound images were obtained
before and immediately after establishing intravenous access. A
peel-away sheath was then placed over a guidewire and a
double-lumen PICC line measuring 36 cm in length was then placed
through the peel-away sheath with its tip positioned in the SVC
under fluoroscopic guidance. Position of the catheter was
confirmed by a fluoroscopic spot film of the chest.
The peel-away sheath and guidewire were then removed. The
catheter was
secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no
immediate
complications.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided
5 French
double-lumen PICC line placement via the left brachial venous
approach. Final internal length is 36 cm, with the tip
positioned in SVC. The line is ready to use.
After placing the left-sided PICC line, the right PICC line,
which is thought to be infected, was removed and the tip sent
for culture and sensitivities. Sterile dressings applied.
[**2115-3-17**]: Portable Abdomen
HISTORY: Improving SBO, known dilated colon. Abdominal
distention.
SUPINE & UPRIHT ABDOMEN:
Slightly improvement of diameter of prominent loops of large
bowel measuring up to 6.4 cm and previously measured up to 11
cm. There is no free intraperitoneal air or pneumatosis.
IMPRESSION: Slightly improvement of mildly dilated loops of
large bowel. No free intraperitoneal air.
[**2115-3-19**]: Left Wrist
LEFT WRIST
CLINICAL HISTORY: Trauma and pain.
AP and lateral films of the wrist and a somewhat motion limited
AP film of the forearm were obtained. On the somewhat oblique
lateral film there is a
vertical lucency projected at the anterior aspect of the radius
which is
probably artifactual. No fracture is seen on the AP view. The
carpal bones
are normally aligned.
IMPRESSION: The study is somewhat technically limited. No
definite fracture is seen. If the patient's symptoms persist, a
repeat view might be of use.
[**2115-3-19**]: LEFT HUMERUS
CLINICAL HISTORY: Fracture.
AP, oblique and scapular Y views of the left humerus were
obtained.
There is a fracture in the region of the surgical neck of the
humerus with
medial displacement of the shaft relative to the humeral head. A
catheter
likely a PICC line, is noted.
IMPRESSION:
There is a mildly displaced fracture in the region of the
surgical neck of the left humerus.
[**2115-3-20**]: CT Torso
CLINICAL INDICATION: History of cerebral palsy with SMV
occlusion, partial
small-bowel obstruction, colonic and retroperitoneal hemorrhage
with worsening abdominal distention, tenderness, hematocrit drop
and fever.
TECHNIQUE: MDCT of the chest, abdomen and pelvis was performed
following the uneventful administration of nonionic intravenous
contrast and oral contrast. Comparison exam is dated [**2115-3-13**].
FINDINGS:
CHEST: There are small bilateral pleural effusions, increased
from the prior exam. There are calcifications of the aortic
valve, and the ascending aorta is ectatic, measuring 3.9 cm. The
descending aorta is normal in caliber. A right-sided venous
catheter terminates in the SVC. There are no pathologically
enlarged thoracic lymph nodes.
Lung windows demonstrate compressive atelectasis. There are no
focal nodules or masses. The central airways are patent.
ABDOMEN: The liver, spleen, left kidney, adrenal glands are
unremarkable.
The gallbladder is surgically absent. There is a stable right
renal
hypodensity. Again noted is atrophy of the pancreas with
calcifications in
the head, consistent with chronic pancreatitis. A feeding tube
terminates in the duodenum.
Compared to the prior exam, there has been interval resolution
of small bowel dilatation. Colonic wall thickening has also
improved, with minimal residual thickening in the descending
colon in the area of prior hemorrhage. There is increased
abdominal ascites. Again noted is occlusion of the superior
mesenteric vein, with numerous collaterals. The portal veins are
patent. Left retroperitoneal hemorrhage is stable.
PELVIS: Previously seen hemorrhage interposed between the rectum
and bladder is resolved. There is increased pelvic ascites with
some layering high density posteriorly. There is stable rectal
and sigmoid thickening. There are no pathologically enlarged
lymph nodes.
Bone windows demonstrate degenerative changes and scoliosis,
without focal
suspicious lesion.
IMPRESSION:
1. Interval resolution of small bowel dilatation, and near
interval
resolution of high density thickening of the descending colon.
Persistent
sigmoid and rectal thickening. Increased abdominal and pelvic
ascites with
some layering high density posteriorly. Stable left
retroperitoneal bleed and interval resolution of hemorrhage seen
between the rectum and bladder.
2. Small bilateral pleural effusions, increased from the prior
exam.
3. Stable occlusion of the SMV, with numerous collaterals.
4. Dilatation of the ascending aorta and marked calcification of
the aortic valve for the patient's age. This finding could
indicate a bicuspid valve.
[**2115-3-24**]: CTA CHEST AND CT ABDOMEN AND PELVIS WITH CONTRAST
INDICATION: 35-year-old man with sudden onset of hypoxia,
tachypnea and fever since yesterday. Known SMV clot, evaluate
for PE.
COMPARISON STUDY: CT torso from [**2115-3-20**] and chest x-ray from
[**2115-3-24**].
TECHNIQUE: MDCT of the chest, abdomen and pelvis was performed
following the uneventful administration of nonionic intravenous
contrast. Coronal, sagittal and multiple oblique reformatted
images were reviewed per PE protocol.
FINDINGS:
CHEST: The endotracheal tube is in satisfactory position. An NG
tube
terminates within the stomach. The ascending aorta is mildly
ectatic at 3.8 cm. The descending aorta is normal in caliber. A
left-sided PICC line
terminates in the SVC. There are no enlarged axillary,
mediastinal or hilar lymph nodes.
There is new patchy multifocal airspace consolidation,
particularly within the left upper lobe and medial segment right
middle lobe consistent with
pneumonia. There are increased moderate bilateral pleural
effusions with
compressive atelectasis.
There is no pulmonary embolism within the main, lobar or
segmental pulmonary arteries.
ABDOMEN: There is new ill-defined area of hypoattenuation within
segment V of the liver measuring 2.8 x 3.5 cm. This may
represent a developing abscess. There is stable marked ascites.
The patient is status post cholecystectomy. The spleen, pancreas
and adrenal glands are unremarkable. The kidneys have symmetric
nephrograms. There is a 1.2 cm low attenuating lesion within the
mid pole right kidney, incompletely assessed on this
contrast-enhanced study. There is no evidence of small-bowel
obstruction. There is stable thickening of the sigmoid colon and
rectal wall. There is continued dilation of the colon. There is
a stable left retroperitoneal hemorrhage which now appears more
organized.
Bone windows show degenerative change and scoliosis without
focal suspicious lesion.
IMPRESSION:
1. New bilateral patchy pneumonia, particularly within the left
upper lobe
and right middle lobe.
2. New ill-defined 2.8 x 3 cm hypoattenuating lesion in segment
V of the
liver. This may be secondary to a developing abscess. Follow-up
ultrasound
is recommended in 3 days.
3. Persistent sigmoid and rectal thickening with stable marked
abdominal and pelvic ascites.
4. Stable left retroperitoneal bleed, more organized.
5. Increased moderate bilateral pleural effusions.
[**2115-3-25**]: Transthoracic Echocardiogram
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. Regional
left ventricular wall motion is normal. There is mild to
moderate global left ventricular hypokinesis suggested(LVEF = 45
%). There is no ventricular septal defect. Right ventricular
chamber size and free wall motion are normal. The number of
aortic valve leaflets cannot be determined. There is moderate
aortic valve stenosis (valve area 1.0-1.2cm2). The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2115-2-19**], the
patient is more tachycardic. The LV systolic function now
appears depressed. The aortic valve gradient appears similar. If
indicated, a TEE would better clarify the basis and severity of
the aortic stenosis (as well as global LV systolic function).
[**2115-3-27**]: RUQ Ultrasound
INDICATION: 35-year-old man with possible liver abscess, to
assess for
interval change.
COMPARISON: CT torso, [**2115-3-24**].
FINDINGS: Liver has a normal echotexture without evidence of
focal liver
lesions. The hypoenhancing lesion, seen in the prior CT scan, is
not
visualized in the ultrasound study. This likely represents an
infarct of the liver, secondary to compromised blood supply
through the right portal vein. There is no intrahepatic or
extrahepatic biliary dilatation. Patient is status post
cholecystectomy. Common duct measures 5 mm.
A moderate amount of right pleural effusion and ascites are
seen.
IMPRESSION:
1. No son[**Name (NI) 493**] correlate corresponding to the hypoenhancing
lesion seen on prior CT of [**2115-3-24**] is seen. Lesion seen on CT
could represent an infarct secondary to compromised blood supply
through the right portal vein, which appears nearly occluded.
2. Right pleural effusion and ascites.
[**2115-4-2**]: Transthoracic Echocardiogram
Right ventricular chamber size is normal. with mild global free
wall hypokinesis. The number of aortic valve leaflets cannot be
determined. The aortic valve leaflets are moderately thickened.
No masses or vegetations are seen on the aortic valve, but
cannot be fully excluded due to suboptimal image quality. There
is moderate aortic valve stenosis (valve area 1.0-1.2cm2). No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen.
IMPRESSION: Moderately thickened and deformed aortic valve
leaflets with moderate to severe stenosis. At least moderate
mitral regurgitation. Small echodensity in the left atrium
adjacent to the anterior leaflet of the mitral valve (clip [**Clip Number (Radiology) **])
which appears consistent with artifact from mitral annular and
valvular calcification; however, a small vegetation cannot be
excluded. Mild global biventricular hypokinesis.
If clinically suggested, the absence of a vegetation by 2D
echocardiography does not exclude endocarditis.
Compared with the prior study (images reviewed) of [**2115-3-25**],
the findings are similar.
[**2115-4-3**]: Video Oropharyngeal Swallowing Study
INDICATION: 35-year-old man with pneumonia, assess for
aspiration.
VIDEO OROPHARYNGEAL SWALLOWING FLUOROSCOPY: Oropharyngeal
swallow fluoroscopy was performed in conjunction with the speech
and swallow division. This is a limited study with nectar and
thick consistencies of barium only used. No aspiration or
penetration was noted for nectar or thick consistencies.
IMPRESSION: Limited study with no aspiration or penetration for
thick and
nectar consistencies. For additional details, please see OMR
speech and
swallow division note.
[**2115-4-5**]: Portable CXR
AP CHEST, 09:48 A.M., [**4-5**]
HISTORY: Shortness of breath, question interval change.
IMPRESSION: AP chest compared to [**3-27**] through [**4-4**]:
Pulmonary edema has cleared from the periphery of the lungs.
Central
consolidation persists. Whether this is pneumonia or pulmonary
edema is
radiographically indeterminate. Small bilateral pleural
effusions are
presumed. Heart size is normal. Mediastinal vascular engorgement
persists. No pneumothorax. Nasogastric tube ends in the third
portion of the duodenum.
Brief Hospital Course:
# Abdominal pain: The patient presented with abdominal pain. The
patient was found to have a pancreatic cyst, SMV thrombus,
ascites and diffuse bowel thickening. The pancreatic cyst was
seen on prior images and felt to be unchanged in appearance. The
SMV thrombus appeared chronic in nature. He was started on
anticoagulation that will need to be continued for at least 6
months. This should be followed by the vascular surgeons. The
ascites had a diagnostic tap which showed a leukocytosis. He was
broadly covered with vancomycin and zosyn for secondary
peritonitis. No bacteria grew on cultures. He had a total of 2
weeks of this course. The patient also had diffuse bowel
thickening that was of unknown etiology but concerning for edema
vs inschemia. He had a low lactates so edema more likely. The
patient had a CTAP on [**2-25**] which showed partial small bowel
obstruction vs ileus and gas in the bowel suggestive of a
microperforation. Surgery was contact[**Name (NI) **] and the patient was kept
on intermittent low suction and remained NPO. He received
another 2 weeks of antibiotics with ciprofloxacin and
metronidazole. After he finishes his course of antibiotics he
will need another imaging study to evaluate for ascites. If he
does have ascites he will need a paracentesis with cell count
and differential. The patient passed speech and swallow and was
fed with PO food. His pain was controlled with IV morphine and
tylenol. At the time of discharge the patient had no evidence of
abdominal pain and was not requiring analgesics.
.
# GIB: On [**3-13**], Mr. [**Known lastname 32665**] developed coffee-ground emesis,
abdominal pain, Hct drop (30.8 to 24.6) and hypotension to SBPs
in the 60s, and was transferred to the MICU. He received 3 units
of pRBCs in response to Hct drop with appropriate response. He
was seen by GI and the general surgery service, and CT scan of
the abdomen was obtained showing retroperitoneal bleed.
Anticoagulation for SMV thrombosis was held, and the patient's
abdominal pain improved steadily over 48 hours, at which time
his family felt that he was back to his baseline and abdominal
distension (appreciated on transfer) had resolved. NGT placed to
suction showed no further evidence of UGIB, so endoscopy was
deferred. The patient was initially placed on low-dose
phenylephrine to maintain SBP > 75, but this was weaned within
48 hours. SBPs remained low (upper 70s-90s) but this was
consistent with patient's recent baseline and small size. He was
observed in the unit for an additional 24 hours, during which
time Hct and BPs remained stable, and he was called out to the
floor. There were no more GIB episodes since then. His hct has
been stable during the rest of his hospital stay.
.
# Humeral fracture: The patient was noted to have left arm pain
after he got a new PICC line in the MICU. A x-ray of the LUE
was done, which showed left humeral fracture. It was unclear
what caused the fracture. The suspicion is that the fracture
occured when he was down in the radiology department to get PICC
line. Patient was seen by orthopedics, who recommended a repeat
shoulder film. After all the imaging was obtained, orthopedics
recommende......
.
# Nutrition: The patient presented with a very low albumin level
suggesting very poor nutrition status. The patient was started
on TPN and remained NPO. As his abdominal pain improved he was
started on slow tube feeds which he tolerated well. The patient
passed a speech and swallow evaluated and ate PO food and the
NGT was discontinued. He will need to continue TPN for the next
month. He should also consider a PEG tube as his prior nutrition
was inadequate.
.
# Acute renal failure: The patient has a baseline of 0.4-0.5.
His creatinine peaked at 1.2. The most likely etiology was
thought to be secondary to ATN secondary to nephrotoxic [**Doctor Last Name 360**].
IVF failure to return Cr to baseline. He had medications renally
dosed and nephrotoxins were avoided.
.
# Anemia: The patient has a baseline Hct of 35. He was guaiac
and NG lavage negative on admission. He required multiple
transfusions for Hct under 21. He showed some anemia of chronic
disease/iron deficiency anemia. No evidence of hemolysis and
B12, folate normal. Will need iron supplementation as an
outpatient. Patient had GIB and RP hematoma on anticoagulation
on [**3-13**], and anticoagulation was stopped. Patient was
transferred to MICU and required 3u pRBC transfusion. His hct
has been stable during the rest of his hospital stay.
.
# Respiratory failure: The patient was intubated for respiratory
failure. The patient had a LLL infiltrate on CXR. He was treated
with vancomycin and zosyn for HAP/VAP. The patient was extubated
and quickly weaned to room air with normal oxygen saturation.
.
# SMV occlusion: This appears to be chronic given the number of
collaterals. He will need to be maintained on anticoagulation
for 6 months per vascular surgery. He was on a lovenox bridge to
warfarin with a goal INR of [**1-16**].
.
# Seizure disorder: The patient was started on fosphenytoin and
phenobarbital. His levels were adjusted. He had daily episodes
of "absence seizures". He will need close follow up as an
outpatient. outpatient Neurology Openheimer ([**Hospital1 3597**]).
.
# Hypotension: The patient has a baseline systolic blood
pressure in the 80s. The patient remained near his baseline as
an inpatient.
.
MICU Course [**Date range (1) 86346**]
.
# Hypoxemia: The patient was transferred to MICU with
tachypnea and hypoxia on [**2115-3-23**]. He was initially started on
BiPap and did well for several hours, even weaning off of the
BiPap. Unfortunately, the patient became increasingly hypoxemic
and required intubation on [**2115-3-24**]. Imaging at that time was
consistent with multilobar pneumonia with sputum growing MRSA.
The patient completed an 8 day course of vancomycin, cefepime,
and flagyl on [**2115-3-31**].
.
Pleural effusions were also noted on imaging, likely due to
fluid resuscitation for hypotension in the setting of albumin of
2.3, so the patient was aggressively diuresed with lasix
boluses.
.
Prior to extubation, the patient was made DNR/DNI after long
discussion with family. After optimization, the patient was
extubated on [**2115-3-30**] to face mask and nasal cannula. Oxygen
requirement thought due to pulmonary edema, mucous plugging and
secretions, also restrictive with low lung volumes in setting of
ascites.
.
During the patient's last several days in the MICU, he had
improvement in O2 requirement with continued gentle diuresis.
.
The patient was started on standing lasix 40mg PO BID.
.
# Yeast bacteremia:
The patient was noted to have low grade fevers. On [**3-29**], a
urine culture regurned with > 100k yeast. On [**3-31**], a blood
culture returned that was also growing yeast
We suspected possible urogenital source with hematogenous
spread. Heart rate and blood pressure currently at baseline.
Normal WBC count, lactate.
.
The patient was initially started on micafungin while speciation
and identification were finalized. The infectious disease
service was consulted and followed the patient. The yeast was
speciated as [**Female First Name (un) **] albicans that was fluconazole sensitive.
On the day of discharge the patient was started on fluconazole
and micafungin was discontinued. He should have LFTs monitored
every three days while on fluconazole for a total course of 14
days.
.
The patient's lines and foley catheter were replaced during this
time. A new PICC line was placed on [**2115-4-5**].
.
The patient had daily surveillance blood cultures that did not
show evidence of any further fungemia.
.
Dilated fundoscopic exam on [**4-2**] neg for apparent chororetinal
lesions with signif corneal scarring. Recommend repeat DFE in 2
weeks of if patient having ANY procedure requiring general
anesthesia. On lacrilub gtts.
.
#Fevers:
The patient had daily low grade febrile episodes despite broad
spectrum antibiotics. Completed treatment for pulmonary
infection with 8 day course of vancomycin, cefepime, flagyl.
SBP possible but 3 taps have not been c/w SBP. PE considered
but no evidence on CTA. CT read as possible liver abscess but
repeat RUQ ultrasound read as more consistent with infarct. C.
Diff has been negative. The low grade fevers were then though
to be due to positive urine and blood culture growing yeast.
Repeat cultures of blood, urine ngtd.
.
# Tachycardia:
The patient had persistent tachycardia into the 110s that was
likely hyperdynamic in setting of fever and infection. Volume
status appeared grossly euvolemic; pt mentating at baseline and
maintaining urine output. Echo with evidence of depressed
cardiac fxn, ? tachycardia induced cardiomyopathy. The
patient's baseline HR has been consistently 100-115 bpm.
.
It should also be noted that the patient's baseline systolic
blood pressure is between 80-100 mmHg. We were obtaining blood
pressures via a thigh cuff as this more likely represented his
true blood pressure.
.
# Anemia/bleed:
Pt with retroperitoneal bleed and CT evidence of hemorrhage into
bowel wall, also gastric varices c/b GIB earlier in admission.
He was transfused 1 unit pRBCs [**3-25**] with appropriate bump and
has remained stable since.
.
His hematocrits were trended daily and stools were guaiac
negative.
.
He was continued on PO pantoprazole and iron supplementation.
.
# Liver lesion.
The patient had a Noted on abdominal CT with concern for
possible ischemia/infarction vs abscess. Abdominal U/S [**3-27**] not
consistent with abscess.
.
# Left humeral fx: Likely d/t trauma sustained during radiology.
Patient briefly received morphine for pain control and also
continued to receive lidoderm patches for comfort. No lab draws
were conducted on the left arm. There was no indication for
surgical intervention.
.
# SMV thrombus:
The initial plan for the SMV thrombus was for anticoagulation x
6 months, but in the setting of recent GI and RP bleed all
anticoagulants were discontinued.
.
The patient was restarted on heparin SQ for DVT prophylaxis.
.
# Seizure disorder:
No recent reports of seizures. The patient was maintained on his
home doses of phenobarbitol and fosphenytoin. Drug levels were
checked frequently and were in the therapeutic window.
.
# Cerebral palsy: Stable mental status. Interactive with family
but nonverbal at baseline.
.
FEN: continue tube feeds while fully transitioning to PO diet
cleared for nectar thick liquids, pureed solids; needs 1:1
observation (mother may need to feed). OK to try crushed meds,
but may not take reliably.
.
Medications on Admission:
Medications (Upon admission)
Miralax prn
Phenobarbital 32.4 mg TAB [**12-15**] am, 1PM
Dilantin (Extended caps) 75mg in am 100mg in pm
Ferrous Fumarate 324 mg Tabs daily
MVI daily
Cyproheptadine HCL 4mg tabs 0.5 tab in AM, 0.5 tabs in PM
Prilosec 20mg daily
Celexa 20mg daily
Zovirax 5% oint (acyclovir) q2hr while awake x 4 days prn cold
sore
vitamine D 400 Unit Caps
Medications (Upon transfer to MICU service)
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN low oxygen sats
Piperacillin-Tazobactam 4.5 g IV Q8H
Midazolam 0.5-1 mg IV Q4H:PRN comfort of ETT
Fentanyl Citrate 12.5-100 mcg IV Q2H:PRN pain
Pantoprazole 40 mg IV Q12H
Magnesium Sulfate IV Sliding Scale
Calcium Gluconate IV Sliding Scale
LeVETiracetam 1000 mg IV Q12H
Insulin SC (per Insulin Flowsheet) Sliding Scale
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
Acetaminophen 325 mg PO/NG Q6H:PRN fever, pain
Potassium Chloride IV Sliding Scale
Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **]
Tobramycin 220 mg IV Q24H
Vancomycin 1250 mg IV Q 12H
Heparin IV Sliding Scale
Warfarin 5 mg PO/NG DAILY16
Discharge Medications:
1. Miconazole Nitrate 2 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **] (2
times a day).
2. Camphor-Menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
QID (4 times a day) as needed for itching.
3. Cortisone 1 % Cream [**Hospital1 **]: One (1) Appl Topical QID (4 times a
day) as needed for itching.
4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
5. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Hospital1 **]: One (1)
teaspoon PO DAILY (Daily).
6. Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) [**Hospital1 **]: One (1) Cap PO TID (3 times a day).
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
2-4 Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
8. Acetaminophen 650 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
9. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Hospital1 **]: [**12-15**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
10. Phenobarbital 30 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2
times a day).
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Phenytoin 50 mg Tablet, Chewable [**Last Name (STitle) **]: Two (2) Tablet,
Chewable PO Q 8H (Every 8 Hours).
13. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment [**Last Name (STitle) **]: One
(1) Appl Ophthalmic QID (4 times a day) as needed for dry eyes.
14. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: One (1)
Injection [**Hospital1 **] (2 times a day).
15. Furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
16. Morphine 2 mg/mL Syringe [**Hospital1 **]: [**1-17**] milligrams
milligrams Injection Q4H (every 4 hours) as needed for Pain.
17. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
18. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
19. Fluconazole 400 mg IV Q24H
20. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
Primary:
(1) Hypoxic Respiratory Failure
(2) Health Care Associated Pneumonia
(3) Fungemia
(4) Fungal Urinary Tract Infection
(5) Retroperitoneal Bleed
(6) Superior Mesenteric Vein Thrombus
(7) Large Bowel Obstruction
(8) Acute Peritonitis
(9) Hypotension
(10) Sepsis
(11) Left Humerus Fracture
(12) Gastric Varices
(13) Ascites
(14) Ileus
(15) GI Bleed
Secondary:
(1) Cerebral Palsy
(2) Seizure Disorder
(3) Anemia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive (nonverbal)
Activity Status: Bedbound.
Discharge Instructions:
Mr. [**Known lastname 32665**],
It was a pleasure to care for you during your hospitalization at
the [**Hospital1 69**].
During this hospitalization, you were treated for a superior
mesenteric vein thrombus with blood thinning agents, but
unfortunately you had bleeding in your abdomen that required the
blood thinning medicines to be stopped.
During this hospitalization, you also had difficulty breathing,
likely due to pneumonia and fluid overload, that required
intubation and ventilator assistance.
You further had a pneumonia, and required medications to keep
your blood pressure in a normal range.
An infection was found in your blood as well as your urine
(yeast) and you were treated with anti-fungal medications.
Unfortunately, your left arm was broken during this
hospitalization.
Please continue to take all of your medicines as previously
prescribed before this hospitalization. Do not take any blood
thinning (anticoagulant) medications.
The following medications have been added to your regimen:
(1) Fluconazole 400mg IV ever 24 hours x 14 days
Followup Instructions:
You are being discharged to a rehab facility.
Please contact your primary care physician for [**Name Initial (PRE) **] follow up
appointment in [**12-15**] weeks.
Completed by:[**2115-4-9**]
|
[
"0389",
"51881",
"5845",
"5119",
"2851",
"99592",
"2875"
] |
Admission Date: [**2150-11-7**] Discharge Date: [**2150-11-10**]
Date of Birth: [**2078-6-29**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1781**]
Chief Complaint:
Back Pain
Major Surgical or Invasive Procedure:
1. Exploratory laparotomy and repair of ruptured abdominal
aortic aneurysm with 16-mm tube graft.
History of Present Illness:
ruptured 6.8 cm AAA
Past Medical History:
PMH: none
Social History:
not known
Family History:
not known
Physical Exam:
Deceased
Pertinent Results:
[**2150-11-10**] 12:32AM BLOOD
WBC-2.5* RBC-3.01* Hgb-9.8* Hct-27.1* MCV-90 MCH-32.4*
MCHC-36.1* RDW-15.4 Plt Ct-111*
[**2150-11-10**] 12:32AM BLOOD
Plt Ct-111*
[**2150-11-10**] 12:32AM BLOOD
PT-15.6* PTT-29.3 INR(PT)-1.4*
[**2150-11-10**] 12:32AM BLOOD
Glucose-143* UreaN-38* Creat-5.0* Na-131* K-4.4 Cl-105 HCO3-18*
AnGap-12
[**2150-11-10**] 12:32AM BLOOD
CK-MB-35* MB Indx-0.7 cTropnT-0.21*
[**2150-11-10**] 12:32AM BLOOD
Albumin-1.9* Calcium-7.8* Phos-9.2* Mg-2.6
[**2150-11-10**] 02:11AM BLOOD
Type-ART pO2-49* pCO2-42 pH-7.24* calTCO2-19* Base XS--8
[**2150-11-10**] 02:11AM BLOOD
Lactate-6.0*
[**2150-11-10**] 12:43AM BLOOD
Glucose-132* Lactate-5.6*
[**2150-11-9**] 11:45 pm BLOOD CULTURE
AEROBIC BOTTLE (Final [**2150-11-12**]):
PSEUDOMONAS AERUGINOSA.
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 2 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
ANAEROBIC BOTTLE (Final [**2150-11-13**]):
PSEUDOMONAS AERUGINOSA.
SERRATIA MARCESCENS.
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 2 S
CHEST (PORTABLE AP)
Reason: 72 yo M s/p AAA repair with hypoxia and hypotension
HISTORY: Ruptured AAA. Hypoxia and hypotension.
IMPRESSION: AP chest compared to [**11-7**] through 23:
Moderate to severe pulmonary edema, more pronounced in the right
lung has worsened slightly since 8:21 p.m. on [**11-9**]. The
asymmetry base with the possibility of coexisting aspiration
developing pneumonia in the right lung. Heart is normal size.
Thoracic aorta is stably widened in the region of the aortic
arch. ET tube and Swan-Ganz catheter are in standard placements,
and tip of a left-sided vascular line projects over the left
brachiocephalic vein. Nasogastric tube passes into the stomach
and out of view.
Cardiology Report ECHO Study Date of [**2150-11-9**]
MEASUREMENTS:
Left Atrium - Four Chamber Length: *5.3 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.7 cm (nl <= 5.0 cm)
Left Ventricle - Inferolateral Thickness: 0.9 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.9 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.0 cm
Left Ventricle - Fractional Shortening: *0.18 (nl >= 0.29)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 2.4 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: *2.3 m/sec (nl <= 2.0 m/sec)
Aortic Valve - LVOT Diam: 2.3 cm
INTERPRETATION:
Findings:
LEFT ATRIUM:
No spontaneous echo contrast is seen in the LAA. Good (>20 cm/s)
LAA ejection velocity. No thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM:
Dynamic interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE:
Normal LV cavity size. Normal regional LV systolic function.
Hyperdynamic LVEF.
LV WALL MOTION:
basal anterior - normal; mid anterior - normal; basal
anteroseptal - normal; mid anteroseptal - normal; basal
inferoseptal - normal; mid inferoseptal - normal; basal
inferior - normal; mid inferior - normal; basal inferolateral -
normal; mid inferolateral - normal; basal anterolateral -
normal; mid anterolateral - normal; anterior apex - normal;
septal apex - normal; inferior apex - normal; lateral apex -
normal; apex - normal;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. MR present
but cannot be quantified.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
Dilated main PA.
GENERAL COMMENTS: A TEE was performed in the location listed
above.
The rhythm appears to be atrial fibrillation.
Conclusions:
No spontaneous echo contrast is seen in the left atrial
appendage. No thrombus is seen in the left atrial appendage. No
atrial septal defect is seen by 2D or color Doppler. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) are
mildly thickened. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mitral
regurgitation is mild. The main pulmonary artery is dilated. A
left pleural effusion is visualized.
Brief Hospital Course:
Mr. [**Known lastname 41776**] is a 72-year-old male who underwent an emergent
repair of a ruptured abdominal aortic aneurysm on [**2150-11-7**]. He had massive blood
loss and operative resuscitation, and his abdomen was left open.
This was performed by Dr. [**Last Name (STitle) **].
After pt was stabilized, he wastaken to the operating room for
washout and
possible abdominal closure. During the procedure the patient
began going
back into rapid atrial fibrillation with a heart rate in the
160s and dropping blood pressure to the 60s and 70s.
Despite rebolusing with amiodarone and multiple attempts at
cardioversion, the patient was unable to be converted to a
stable sinus rhythm and remained very unstable.
At this point, the procedure was aborted and the patient was
taken back to the intensive care unit for additional management
and resuscitative efforts.
The patient was then transferred to the surgical intensive care
unit in critical and unstable condition.
Pt was ocked x 6, started on amniodarone, vasopressin and
levophed gtt, transported back up to the unit,
Pt deceased with related problems from severe hypotension s/p
AAA rupture
MI / ARF / ATN / SEPSIS
Medications on Admission:
not known
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
ruptered AAA
Discharge Condition:
deceased
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2150-12-2**]
|
[
"2762",
"5845",
"9971",
"42731",
"2875"
] |
Admission Date: [**2146-11-9**] Discharge Date: [**2146-11-17**]
Date of Birth: [**2089-2-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
Acute renal failure, thrombocytopenia, leukocytosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
57 y/o with DM, hyperlipidemia, metastatic renal cancer with
mets to chest wall, anterior peritoneum, L3 vertebra), s/p right
nephrectomy, failed IL2 therapy and recently on sumatinib which
was completed 3d prior to presentation, s/p right nephrectomy,
DM, hyperlipidemia presented [**2146-11-9**] with 1.5 weeks of N/V and
diarrhea accompanied by worsened mental status per family.
.
In ED, found to be afebrile but with bandemia (10.7 WBC, 18%
bands), elevated lactate 7, acute renal failure with Cr 10
(baseline Cr 1.2), hyperkalemia (K 6.7), hyperuricemia (18) with
any obvious EKG changes(baseline RBBB). CT head negative. Of
note, she had a CT torso on [**2146-11-7**] without prehydration and
without holding metformin. Treated for hyperkalemia and started
on cefepime empirically.
.
She was admitted to the [**Hospital Unit Name 153**] and treated aggressively with IV
fluids with improvement in renal failure and UOP (1600 cc out
today off lasix). Hyperkalemia resolved with with kayexalate,
calcium gluconate, albuterol, D50/insulin. Hyperuricemia
resolved with rasburicase; tumor lysis syndrome thought
unlikely.
.
Antibiotics broadened to Vanc, Cefepime, Flagyl initially for
possible infection given bandemia with question of abdominal
source given nonspecific abnormalities on CT abdomen in colon
and ?necrosis in peritoneal masses but no infectious source has
been found yet and pt remains afebrile without localizing
symptoms; weaned off vanc today. Has had persistent worsening
thrombocytopenia (plt 37 today). Nausea and diarrhea resolved
and mental status improving per [**Hospital Unit Name 153**] team and family although
with occasional disorientation to time, slurred speech, and mild
memory deficits attributed to persistent uremia.
.
Review of systems: No fevers or chills. No headache, neck
stiffness. No sob or cough. No chest pain or palpatations. No
dysuria. No weakness or loss of sensation. No edema. No rash.
Past Medical History:
PAST ONCOLOGIC HISTORY:
======================
Metastatic renal cell cancer: Originally presented with anemia
and a large 16 x 11 cm mass was picked in her right kidney, a 5
x 3.5 cm chest lesion, and a L3 bony lesion. On [**2146-2-17**], she had a laparoscopic nephrectomy for a clear cell
carcinoma with predominantly grade 3 focal sarcomatoid features.
The chest lesion was biopsied on [**2146-2-21**], and was
consistent with metastatic renal cell cancer. The patient then
received IL-2 with poor disease response.
<br>
PAST MEDICAL HISTORY:
====================
Anemia
Hypertension
Diabetes
Hyperlipidemia
Renal cell cancer s/p nephrectomy, lung bx for met, and L3 met
with ongoing back pain
C-section
Open cholecystectomy
Social History:
EtOH: Rarely, never abused
Tobacco: Never used
Retired high school English teacher. She is married and lives
with family in [**State 2748**].
Family History:
Mother died of leukemia at age of 55
Paternal grandmother died of breast cancer at age of 55
Maternal aunt with breast ca
no family history of blood clots
Physical Exam:
VS: T 97.6, BP 154/92, HR 84, RR 15, O2sat 97% 2LNC, I [**2127**], O
1600
Gen: Obese female in NAD
HEENT: NCAT, slightly dry mucous membranes
NECK: Obese neck - did not appreciate JVD
CV: RRR, +S1/S2
Lungs: Mild bibasilar crackles
Abdomen: +BS, soft, obese, non-tender, 4-5cm abdominal wall mass
in RLQ
Extrem: no edema, +pneumoboots
Skin: WWP, some patches of hypopigmentation
Neuro: Awake, Alert, oriented to person, [**Hospital1 18**], year, month, but
not day. Speech slow at times but fluent. CN II-XII grossly
intact. Moves all extremities independently. Finger-to-nose
intact. Toes downgoing on Babinski. Gait not observed.
Pertinent Results:
Admit Labs: [**2146-11-9**]
WBC-10.7# RBC-5.12# Hgb-15.5# Hct-48.0# MCV-94 MCH-30.3
MCHC-32.3 RDW-18.3* Plt Ct-84*
Neuts-76* Bands-17* Lymphs-5* Monos-1* Eos-0 Baso-0 Atyps-0
Metas-1* Myelos-0
Plt Smr-LOW Plt Ct-84*
Fibrino-135*
Glucose-98 UreaN-114* Creat-9.5*# Na-141 K-6.7* Cl-96 HCO3-19*
AnGap-33*
ALT-11 AST-35 LD(LDH)-454* CK(CPK)-237* AlkPhos-84 TotBili-0.4
D-Dimer-6341*
Hapto-325*
Osmolal-345*
pO2-42* pCO2-50* pH-7.22* calTCO2-22 Base XS--7 Comment-GREEN
TOP
Lactate-7.2* K-6.0*
freeCa-1.20
.
Discharge Labs:
.
.
.
.
.
[**2146-11-9**] CXR: No acute intrathoracic process.
[**2146-11-9**] CT head: No acute intracranial process.
[**2146-11-9**] Renal U/S: Normal-appearing left kidney with no
hydronephrosis.
Normal-appearing right renal nephrectomy bed. Small-to-moderate
amount of intra-abdominal ascites and a trace right pleural
effusion.
Brief Hospital Course:
This is a 57 y/o with metastatic renal cell CA presents with
N/V, ARF, hyperkalemia, lactic acidosis, bandemia. Thought to
have metabolic derangements initiated with Sutent leading to
nausea/vomiting, decreased po intake which in conjunction with
continuation of metformin lead to acute renal failure and lactic
acidosis. Now iimproving and transferred to floor for further
management.
.
# ARF: Etiology likely multifactorial. Renal was consulted and
suspected prerenal etiology after sutent therapy with nausea and
vomiting, with component of contrast exposure. UA and culture
done sig for proteinuria and Urine eos neg. A renal ultrasound
did not show hydronephrosis. Patient improved with IV fluids.
Her Cr on discharge was 1.1. Patients [**Last Name (un) **] and HCTZ were held and
not restarted on discharge; she was instructed to follow up with
her PCP to have [**Name Initial (PRE) **] Cr check and determine when to restart these
home medications.
.
#. Anion gap metabolic Acidosis: Lactic acid likely secondary to
metformin, global hypoperfusion, and possibly necrotic
peritoneal mass on CT scan. Improved with IV fluids. Antibiotics
were started for now for possible intraabdominal infection.
.
# Leukocytosis: Initial concern for infection of abdominal
source given possible intraabdominal necrosis and she was
started on vancomycin, cefepime, and flagyl. The patient
remained afebrile with no localizing symptoms. CXR and UA neg.
These medications were stopped because of concern for medication
induced thrombocytopenia.
.
# Thromboyctopenia: DIC and TMA work-up negative. Ultimately
this was thought to be due to antibiotic regimen and sutent, and
so all of these medications were held. Heparin was held and HIT
antibody sent (pending). Platelet on discharge was 23. Patient
no longer wanted to remain in the hospital, and so outpatient
follow up with daily CBC draws at her PCP was arranged, who
could transfuse FFP as necessary.
.
#. DM: All oral hypoglycemics were held. Patient was maintained
on ISS, however, had very little insulin requirement as her FSG
were relatively well controlled 130-160. She was discharged
with the instruction to hold hypoglycemics and follow up with
outpatient PCP.
.
#. HTN: BP meds initially held. Patient was slowly restarted on
her home medications. She was not restarted on her HCTZ or [**Last Name (un) **]
given her RF (as above). Her blood pressure was difficult to
control with BPs 180s/90s, and norvasc was added for better
blood pressure control.
.
# Renal cell Cancer: Sunitinib was held and patient was given
instructions to follow up with her oncologist.
Medications on Admission:
Clonidine 0.3mg PO BID
gabapentin 300mg PO q8h
metformin 500mg PO BID
metoprolol succinate 100mg daily
oxycotin 40mg PO q8hs
Prochlorperazine maleate 5mg [**1-21**] tab q8hr prn
Rosuvastatin 10mg daily
sitagliptin 100mg PO daily
sunitinib 50mg PO daily for 28days followed by 14 days off
treatment
Telmisartan - HCTZ 80mg-25mg Tablet daily
Niacin 750mg SR daily
Discharge Medications:
1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
2. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Niacin 750 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
5. OxyContin 40 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO every eight (8) hours as
needed for pain.
6. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every eight (8)
hours as needed for nausea.
7. Outpatient Lab Work
Please have a Chem 7 checked.
8. Outpatient Lab Work
Please have daily CBC checked.
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO every eight
(8) hours.
10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Vna of [**State **]
Discharge Diagnosis:
Primary Diagnosis:
1) ARF
.
Secondary Diagnosis:
1) Metastatic renal cell cancer
2) Anemia
3) Hypertension
4) Diabetes
5) Hyperlipidemia
Discharge Condition:
Stable: T 97 BP 120/80 HR 61 O2 100/RA
Platelets: 23
Creatine: 1.1
Discharge Instructions:
You were admitted with dehydration, electrolyte and metabolic
abnormalities, called lactic acidoses. This was corrected by
holding your metformin and giving you IV fluids. You had poor
kidney function, measured by an elevated Creatine, and so we
also held your medication called Telmisartan - HCTZ. You
initially had a high white blood cell count that was treated
with antibiotics. During your hospitalization, you were found to
have low platelets. We think that your low platelets were from
the antibiotics that you received so we stopped your
antibiotics. You will need to have your platelets followed
daily until they trend up. Your last platelet count on [**2146-11-17**]
was 23.
.
We have stopped the following medications:
1) Do not take metformin any longer, we believe this could have
contributed to your lactic acidosis.
2) Do not take sitagliptin, your PCP will decide what
medications you should be on for your Diabetes.
3) Do not take Telmisartan - HCTZ. You should have him check
your Cr before restarting this; your Creatine on discharge was
1.1. Your PCP will decide when to restart this medication.
4) Do not restart sunitinib, your oncologist will decide what
therapy you should be on.
.
We have added the following medication:
3) We have started you on amlodipine for your high blood
pressure.
.
Please seek medical care if you develop chest pain, shortness of
breath, confusion, dizziness, fainting, fevers, nausea,
vomiting, or diarrhea.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 80739**]. We have arranged
that you have labs drawn every day to follow your platelets and
make sure that they increase. You should also have your
creatine checked. Please schedule an appointment with your PCP
to decide what diabetic medications you should be on and when to
restart your Telmisartan - HCTZ. The number to his office is
[**Telephone/Fax (1) 80740**].
You also have appointments with the following physcians:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2146-12-26**] 2:00
Provider: [**Name10 (NameIs) 10838**] [**Name11 (NameIs) **], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 22**]
Date/Time:[**2146-12-26**] 2:00
Completed by:[**2146-11-23**]
|
[
"5849",
"2762",
"25000",
"2767",
"2724",
"4019"
] |
Admission Date: [**2146-7-23**] Discharge Date: [**2146-7-29**]
Date of Birth: [**2084-5-9**] Sex: M
Service: Transplant Surgery
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 62-year-old
male with type 2 diabetes, hypertension, end-stage renal
disease (on hemodialysis since [**2145-5-5**]), and has been on
the kidney transplant list for the past three months.
The patient reports doing well without any complaints. He
does have a left arteriovenous graft which is working well.
In his workup, the only abnormality noted was in [**2146-5-5**]. A thallium study showed a small area of ischemia in
the high lateral wall. The patient saw his cardiologist (Dr.
[**Last Name (STitle) 34313**] earlier this week who said the patient was cleared
for transplant (per patient report).
The patient presented on [**2146-7-23**] for a cadaveric renal
transplant.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus since the age of 40.
2. Left arteriovenous graft; working well. He has been on
hemodialysis since [**2145-5-5**] at the [**Location (un) 4265**] [**University/College **]
Dialysis Center two times per week.
3. Kidney stones.
4. Hypertension.
5. Neuropathy.
6. Retinopathy.
7. Right Charcot foot.
8. Status post appendectomy.
9. Pilonidal cyst.
ALLERGIES: INTRAVENOUS CONTRAST DYE (some nausea).
MEDICATIONS ON ADMISSION:
1. Regular insulin 20 units subcutaneously q.a.m. and 10
units subcutaneously q.p.m.
2. NPH 30 units subcutaneously q.a.m. and 28 units
subcutaneously.
3. Avandia 8 mg by mouth every day.
4. Zestril 40 mg by mouth once per day.
5. Nephrocaps.
6. Neurontin.
7. Diovan 20 mg by mouth four times per day as needed.
8. Elavil.
SOCIAL HISTORY: A 35-pack-year tobacco history; quit eight
years ago. Occasionally drinks alcohol.
PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 99.2,
blood pressure was 135/80, heart rate was 104, respiratory
rate was 22, and oxygen saturation was 100% on room air. In
general, in no acute distress. Skin was warm and dry. Head,
eyes, ears, nose, and throat examination revealed the
oropharynx was clear. Sclerae were anicteric. The neck was
supple. No jugular venous distention. No lymphadenopathy.
Cardiovascular examination revealed a regular rate and
rhythm. Normal first heart sounds and second heart sounds.
No murmurs, rubs, or gallops. The lungs were clear to
auscultation bilaterally. The abdomen was obese. Bowel
sounds were present. Soft, nontender, and nondistended. No
hepatosplenomegaly. Back revealed there was no
costovertebral angle tenderness or spinal tenderness.
Extremity examination revealed there was no edema. There
were venous stasis changes. The left arm had an
arteriovenous graft thrill. Neurologic examination revealed
alert and oriented. Normal neurologic examination. Cranial
nerves were intact. Decreased reflexes bilaterally
symmetrically in the lower extremities.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed white blood cell count was 6.6, hematocrit was 34.3,
and platelets were 218. Sodium was 138, potassium was 3.8,
chloride was 93, bicarbonate was 32, blood urea nitrogen was
21, creatinine was 5.4, and blood glucose was 253. ALT was
23, AST was 26, alkaline phosphatase was 96, and total
bilirubin was 0.3. The urinalysis showed 3 to 5 white blood
cells, 0 to 2 epithelial cells, trace leukocyte esterase, and
negative nitrites. Negative hepatology serologies.
PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed some
fullness around the mediastinum. There were no infiltrates.
Electrocardiogram revealed a normal sinus rhythm at 95.
Normal axis and normal intervals. There were small Q waves
in leads I and aVL.
Echocardiogram in [**2145-12-5**] revealed an ejection
fraction of 55% with trace mitral regurgitation.
A stress thallium in [**2145-12-5**] by Dr. [**Last Name (STitle) 34313**] indicated
a small area of ischemia in the high lateral wall.
A colonoscopy was normal in [**2146-2-5**].
A chest computed tomography indicated mediastinal fullness
secondary to adipose tissue. No lymphadenopathy.
SUMMARY OF HOSPITAL COURSE: Mr. [**Known lastname **] is a 62-year-old
male with end-stage renal disease secondary to diabetes and
hypertension who presented on [**2146-7-23**] for a cadaveric
renal transplant.
Consent was obtained, and the patient was taken to the
operating room. The operation went without any
complications.
Postoperatively, in the Recovery Room, the patient became
hypotensive with systolic blood pressures running in the 70s
to 90s. He was bolused several times. An electrocardiogram
revealed no ischemic changes. Cardiac enzymes were sent.
The patient was placed on a dopamine drip running between 2
mcg/kg and 5 mcg/kg per minute with minimal resolution of
hypotension and anuria/oliguria. Neo-Synephrine was added
(by the request of the Transplant fellow). Additionally,
continuous positive airway pressure was started given the
patient's history of sleep apnea. The patient's blood
pressure stabilized in the 120s to 130s/50s to 60s. The
patient was eventually weaned off both the Neo-Synephrine and
dopamine. Repeat arterial blood gases showed marked
improvement.
In the Recovery Room, his potassium was 5.8. The patient was
hemodialyzed. The patient was started on thymoglobulin,
CellCept, Solu-Medrol, and the usual prophylaxis with Bactrim
and Valcyte.
The patient remained in the Vascular Intensive Care Unit
during dialysis for closer monitoring given his cardiac
enzymes which were sent. His troponin T had slightly risen
from 0.07 to 0.14, and Cardiology was consulted. The patient
was started on Lopressor 12.5 mg by mouth twice per day as
well as aspirin 81 mg by mouth once per day. Cardiology did
not believe that the patient had a myocardial infarction, but
they continued to monitor him closely. The patient remained
on telemetry throughout his hospital course.
Given the patient's delayed graft function, slight increase
in troponin level were not unexpected by the Renal team. The
patient's urine output was carefully monitored as well as his
electrolytes. The patient was requiring 2 liters to 3 liters
of oxygen via nasal cannula daily to maintain saturations in
the 90s. A chest x-ray revealed bilateral pleural effusions,
a moderate-sized pleural effusion on the right side. At that
point, we decided to diurese the patient with Lasix. We sent
the patient home on Lasix 60 mg by mouth twice per day.
The patient's primary care physician was [**Name (NI) 653**], and we
were informed that the patient regularly has an oxygen
saturation in the 80s. Given his saturation of 72% on room
air with ambulation, the patient was discharged with oxygen
as well as pulse oximetry with teaching provided by
Respiratory Therapy.
The patient had a short course of levofloxacin. Given his
x-ray with a significant pleural effusion, we could not rule
out an infiltrate. This antibiotic was discontinued by the
time of discharge, and his chest x-ray showed marked
improvement.
The patient received five doses of thymoglobulin as well as a
Solu-Medrol taper. He was discharged on tacrolimus at a dose
of 6 mg by mouth twice per day and CellCept [**Pager number **] mg by mouth
twice per day.
The patient continued to do well. He was tolerating solids
and ambulating regularly. To improve his pulmonary
condition, chest physical therapy and pulmonary toilet were
provided.
The patient's urine output continued to improve, and he did
not require any further dialysis.
On postoperative day six, the patient was thought to be
stable for discharge with home oxygen and pulse oximetry.
The patient was scheduled to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **]
at the Transplant Center on [**8-1**] and with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on [**8-9**]. The patient was discharged with
prescription for Percocet, potassium, Lasix, and oxygen.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE DIAGNOSES:
1. End-stage renal disease secondary to diabetes and
hypertension.
2. Status post cadaveric renal transplant; delayed graft
function with marked improvement by the time of discharge.
3. Hypotension most likely secondary to anesthesia.
4. Neuropathy.
5. Sleep apnea.
6. Postoperative hypoxemia.
7. Postoperative hyperkalemia; resolved after dialysis.
8. Ruled out for a myocardial infarction.
MEDICATIONS ON DISCHARGE:
1. Bactrim-SS one tablet by mouth once per day.
2. Valcyte 450 mg one tablet by mouth every other day.
3. Pantoprazole 40 mg by mouth once per day.
4. Colace 100 mg by mouth twice per day.
5. Amitriptyline 50-mg tablets one tablet by mouth once per
day.
6. Nystatin swish-and-swallow.
7. CellCept [**Pager number **]-mg tablets two tablets by mouth twice per
day.
8. Aspirin 81 mg by mouth once per day.
9. Albuterol inhaler 1 to 2 puffs inhaled q.6h. as needed.
10. Metoprolol 25 mg by mouth twice per day.
11. Percocet one to two tablets by mouth q.4-6h. as needed
(for pain).
12. Avandia 8 mg by mouth every day.
13. Insulin sliding-scale as provided for the patient.
14. Furosemide 60 mg by mouth twice per day.
15. Tacrolimus 6 mg by mouth twice per day.
16. Potassium chloride 10-mEq tablets one tablet to be taken
once per day when the patient takes Lasix.
17. Oxygen 2 liters to 3 liters continuous with respiratory
therapy instructing the patient on use of pulse oximetry.
DISCHARGE INSTRUCTIONS/FOLLOWUP:
1. The patient was to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **] at
the Transplant Center in the [**Last Name (un) 2577**] Building (telephone
number [**Telephone/Fax (1) 673**]) on [**2146-8-1**] at 11:30 a.m.
2. The patient was also to follow up with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] at the [**Last Name (un) 2577**] Building on [**2146-8-9**] at 9:20
a.m.
3. The patient was also to follow up with Dr. [**First Name (STitle) **] [**Name (STitle) **]
on [**2146-8-15**] at 9:20 a.m. at the Transplant Center.
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Last Name (NamePattern1) 28937**]
MEDQUIST36
D: [**2146-7-29**] 21:40
T: [**2146-8-10**] 08:55
JOB#: [**Job Number 34314**]
|
[
"40391",
"2767"
] |
Admission Date: [**2167-2-23**] Discharge Date: [**2167-2-27**]
Date of Birth: [**2098-7-23**] Sex: F
Service: NEUROLOGY
Allergies:
Sulfonamides
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
CC: code stroke called at 7:26 pm, at the patient's bedside by
7:30 pm.
HPI: 68 year old left handed woman, with a history of dementia,
HTN, previous breast cancer, who around 6:00 pm became confused.
She had woken up from a nap, and was about to have a cup of tea
with her son, and complained of a headache, and feeling sick.
She
stated to her son that she was having a sinus headache, and had
complained of a headache before she went to bed the previous
night. Her son [**Name (NI) **] [**Name (NI) 15427**] was unable to describe the character
or exact location of the headache. She started to want to vomit
and began to gag. He seated his mother down on the couch, and
she
became more disoriented, so he called 911. By the time the EMS
arrived, she was completely confused as to what they were doing
in the room. A few minutes after they arrived around 6:20 pm,
she
started to slouch in the couch to the left, clench her hands and
started shaking them, her legs were straight out, and she
started
frothing at the mouth with a glazed expression. She was
unresponsive and mute. Prior to this, she had been able to
answer
and understand questions in her normal manner. The episode
lasted
10-15 minutes, and her son thought that she was having a
seizure.
The EMS placed an oxygen mask on her face, and she remained
unresponsive.
Of note she had taken Ibuprofen and Tylenol the previous night
for her headache, and when she woke up in the morning. Her son
had offered to take her to the ER in the morning, but she
mentioned that it was her usual sinus headache, which she saw
her
PCP [**Name Initial (PRE) **]. According to her son, yesterday, they went to [**Name (NI) 15428**] as usual, and she was at her baseline.
By the time that I saw her in the ER, she was already intubated
and paralyzed for airway protection. An ROS was unobtainable.
According to the ER physicians she had a flaccid right sided
paralysis on arrival, which was not appreciable after intubation
and paralysis.
Past Medical History:
Left breast cancer(in records, but son unaware of any history)
asthma vs COPD. Also remote hx of GYN cancer (s/p hysterectomy
in her 20s, further details unknown)
hypertension Benicar stopped a month ago according to her son
mild dementia on formal neuropsych testing(although son states
deficits are no longer mild)-seen by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6817**]
[**2167-11-11**] - Mild intrahepatic biliary dilatation on U/S,
Cholelithiasis w/o son[**Name (NI) 493**] evidence of acute cholecystitis &
she had a UTI.
Past Surgical History:
Tonsillectomy, appendectomy, breast
surgery, hysterectomy, and some sort of bladder neck suspension.
Social History:
SH: Lives in [**Location **] with her son. She goes out of the house
once a day to visit [**Company 2486**]. Capable of ADL's, but does
not
drive or balance a cheque book. Gave up smoking 20 years ago,
prior to that she had been a heavy smoker for 40 years. She does
not drink alcohol or use recreational drugs. She worked in a
cafeteria.
HCP/son [**Name (NI) **] [**Name (NI) 122**] [**Name (NI) 15427**] [**Telephone/Fax (1) 15429**], full code for now
PCP: [**Name10 (NameIs) **] [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 2903**] ([**Hospital1 18**]-[**Location (un) **])
Family History:
Her sister died recently of emphysema
Physical Exam:
T-afebrile BP-in the field her systolic BP had been in the 212,
when she arrived in the ER it was 168/121, on propofol it was
140/71 HR-62 RR-16 O2Sat-100% (on vent)FS 177
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
Breast: L breast scar noted, fullness noted in the left upper
outer quadrant.
ext: no edema
Neurologic examination:
Mental status: Intubated and sedated. Received Narcan (2) in the
field, then she was intubated by rapid sequence method
(etomidate+succ), and sedated with propofol (and also given some
versed)
Cranial Nerves:
Pupils 2 mm bilaterally, sluggishly responsive to light.
Corneals
in tact. Dolls head reflex normal. Gag in tact.
Motor:
Withdraws all 4 extremeties to noxious stimulus.
Reflexes:
2 and symmetric throughout, apart from Achilles jerks which are
+1s.
Right toe is upgoing
Coordination & gait could not be assessed
Labs:
pH 7.33 pCO2 44 pO2 484 HCO3 24 BaseXS -2
[**2167-2-23**]
7:33p
Green Top
Na:142
K:3.6
Cl:100
TCO2:17
Glu:191 freeCa:1.16
Lactate:10.7
pH:7.22
Hgb:15.4
CalcHCT:46
Serum tylenol 18.8, rest of serum and Utox unremarkable
Pertinent Results:
[**2167-2-23**] 07:26PM BLOOD WBC-13.1* RBC-4.86 Hgb-14.3 Hct-43.3
MCV-89 MCH-29.5 MCHC-33.1 RDW-12.5 Plt Ct-384
[**2167-2-24**] 02:46AM BLOOD WBC-17.6* RBC-4.31 Hgb-12.5 Hct-37.3
MCV-87 MCH-29.1 MCHC-33.6 RDW-12.9 Plt Ct-270
[**2167-2-23**] 07:26PM BLOOD PT-12.1 PTT-24.8 INR(PT)-1.0
[**2167-2-23**] 07:26PM BLOOD Fibrino-547*
[**2167-2-25**] 03:05AM BLOOD ESR-30*
[**2167-2-25**] 03:05AM BLOOD Glucose-94 UreaN-14 Creat-0.7 Na-142
K-3.1* Cl-109* HCO3-25 AnGap-11
[**2167-2-25**] 03:05AM BLOOD ALT-9 AST-22
[**2167-2-24**] 02:46AM BLOOD CK(CPK)-88
[**2167-2-24**] 02:46AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2167-2-24**] 02:46AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.6
CT head [**2167-2-23**]
1. Subarachnoid hemorrhage in the left posterior parietal cortex
at the
vertex.
2. No evidence of acute infarct. MRI is more sensitive for the
detection of acute ischemia.
MRI head, MRA / MRV [**2167-2-23**]
1. Extensive areas of signal abnormality with nodular
enhancement throughout
the brain, many of which are centered at the [**Doctor Last Name 352**]-white matter
junction, with
both supra- and infra-tentorial compartments involvement as well
as
involvement of deep [**Doctor Last Name 352**] nuclei.
Differential considerations include an infectious process, which
may be
related to septic emboli (although the lack of more widespread
associated
blood products and infarction is unusual, given the extent of
the
abnormalities), atypical infections such as tuberculosis,
neoplastic processes
such as metastatic disease or lymphoma, toxic metabolic
processes (given deep
[**Doctor Last Name 352**] structure involvement and somewhat bilateral diffuse
symmetric
appearance), as well as other more atypical patterns of emboli,
such as from
an atrial myxoma or bland endocarditis.
2. The left parietal blood products seen on the preceding CT
scan could be
due to septic or bland embolism, or an infectious process.
However, they
could also be indicative of venous ischemia secondary to the
underlying
pathologic process.
3. No evidence of venous sinus thrombosis. While the large
cortical veins
appear patent, MRV is not sensitive for evaluation of cortical
veins.
4. Unremarkable MRAs of the head and neck, without evidence of a
hemodynamically significant stenosis or aneurysm.
5. Areas of increased signal intensity within the left lobe of
thyroid gland,
incompletely characterized on the current study. Correlation
with thyroid
laboratory data and/or ultrasound is recommended.
TTE [**2167-2-24**]
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Left ventricular systolic function is hyperdynamic
(EF>75%). Right ventricular chamber size and free wall motion
are normal. The mitral valve leaflets are structurally normal.
There is no mitral valve prolapse. No mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is a trivial/physiologic pericardial effusion.
There is an anterior space which most likely represents a fat
pad.
IMPRESSION: Normal global and regional biventricular systolic
function.
[**2167-2-24**] CXR
FINDINGS: In comparison with the study of [**2-23**], the
endotracheal tube and
nasogastric tube have been removed. There is a vague suggestion
of an area of
increased opacification in the retrocardiac region on the left.
This could
merely reflect atelectasis or crowding of vessels. However, in
view of the
clinical symptoms, the possibility of a developing aspiration
must be
considered. This area should be closely checked on subsequent
radiographs.
On to recent studies, there is suggestion medial displacement of
the stomach,
which could be associated with enlargement of the spleen.
MR HEAD W & W/O CONTRAST Study Date of [**2167-2-26**] 9:53 PM
IMPRESSION: There has been significant interval improvement in
the extent of
T2/FLAIR-signal abnormality throughout the supra- and
infratentorial
compartments with a similar small volume of subarachnoid
hemorrhage, compared
to the prior study. The enhancement at these sites has resolved
completely.
The overall distribution and evolution strongly suggests the
possibility of
underlying PRES, which may be associated with both enhancement
and hemorrhage
in some cases. There is no associated infarct. Other toxic,
neoplastic or
metabolic etiologies as suggested in the report of the previous
exam remain in
the differential diagnosis, though are now considered
significantly less
likely.
Brief Hospital Course:
Ms. [**Known lastname 15427**] is a 68 year old left handed woman, with a history
of dementia, HTN, a remote history of GYN cancer (in her 20s,
s/p hysterectomy, further details unobtainable), presenting with
several day history of headache followed by sudden-onset
confusion, disorientation, and vomiting, with subsequent
10-minute GTC seizure. She was intubated upon arrival to the
emergency department for airway protection and admitted to the
neurology ICU.
.
Hospital course by problem;
.
Neurology; A CT head revealed a right parietal subarachnoid
hemorrhage. An MRI showed extensive areas of signal abnormality
with nodular enhancement throughout the brain on FLAIR and
post-contrast studies. Given the clinical history, it was
thought these may represent transient post-seizure changes. An
MRA and MRV were unremarkable. She was transferred to the
neurology floor.
An MRI with and without contrast was repeated and showed
significant interval improvement in the extent of
T2/FLAIR-signal abnormality throughout the supra- and
infratentorial compartments with a similar small volume of
subarachnoid hemorrhage, compared to the prior study. The
enhancement at these sites has resolved completely. The overall
distribution and evolution strongly suggests the possibility of
underlying PRES, which may be associated with both enhancement
and hemorrhage in some cases. There is no associated infarct.
The patient was started on keppra 750 mg [**Hospital1 **] for seizure
prophylaxis.
.
Respiratory; The patient was extubated on HD#1 and required a
facemask for oxygenation for the following day. She was weaned
to room air.
.
ID; The patient had a Tmax of 101 on HD#1 and has been afebrile
since. She also has a leukocytosis with WBC 17. Blood
cultures, urine cultures, and CXR have showed no sign of
infectious process. The patient has no nuchal rigidity.
.
CV; The patient was monitored on telemetry with no significant
events. A TTE was unremarkable. She was started on simvastatin.
She was instructed to restart Benicar at discharge.
.
Medications on Admission:
AZELASTINE [ASTELIN] - (Prescribed by Other Provider) - 137 mcg
Aerosol, Spray - twice daily
BECLOMETHASONE DIPROPIONATE [QVAR] - (Prescribed by Other
Provider) - 80 mcg Aerosol - twice daily
CITALOPRAM - (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth once a day
DONEPEZIL [ARICEPT] - 10 mg Tablet - 1 Tablet(s) by mouth once a
day
MEMANTINE [NAMENDA] - 5 mg Tablet - 1 Tablet(s) by mouth daily
OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day
OXYBUTYNIN CHLORIDE - 5 mg Tab,Sust Rel Osmotic Push 24hr - 1
Tab(s) by mouth daily
Medications - OTC
DOCUSATE SODIUM [COLACE] - (OTC) - Dosage uncertain
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Levetiracetam 250 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
3. Benicar HCT 40-12.5 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. Memantine 5 mg Tablet Sig: One (1) Tablet PO once a day.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
8. Oxybutynin Chloride 5 mg Tab,Sust Rel Osmotic Push 24hr Sig:
One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
left parietal subarachnoid hemorrhage
seizure
Discharge Condition:
Mental Status: Awake, Alert, oriented x 2 (her baseline). Able
to say DOW forward
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
You were admitted after you had a seizure. You were found to a
left-sided parietal subarachnoid hemorrhage in your brain. Your
brain imaging also shows areas of your brain that may have been
affected by high blood pressure in the setting of being off
Benicar for the past month. Repeat imaging prior to your
discharge showed that these areas were improving.
You should re-start Benicar for blood pressure control. We also
have started you on Simvastatin to help with your cholesterol
level. In addition, since you had a seizure you have been
placed on Keppra 750 mg twice daily for seizure prophylaxis.
You should stay on Keppra for at least 6 months.
Please take all medications as prescribed.
Please follow-up with your neurologist, Dr. [**Last Name (STitle) **], as listed
below.
Should you develop any symptoms as listed below or concerning to
you, please call your doctor or go to the emergency room.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 640**] [**Last Name (NamePattern4) 3445**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2167-3-31**] 5:30
Completed by:[**2167-3-7**]
|
[
"4019"
] |
Admission Date: [**2160-10-2**] Discharge Date: [**2160-10-2**]
Date of Birth: [**2080-1-21**] Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
cardiac arrest
Major Surgical or Invasive Procedure:
EMS intubated
[**Hospital3 417**] Hospital: RIJ and RFA IABP and RFV PA catheter
[**Hospital1 18**]: L arterial line
History of Present Illness:
80 year old woman with atrial fibrillation on coumadin and a h/o
rheumatic heart disease who is transferred from [**Hospital3 417**]
Hospital s/p VFib arrest with cardic cath demonstrating 3-vessel
disease.
.
The history is obtained via report from [**Hospital3 **]. Per report,
the patient was sitting at the breakfast table this morning when
she had a witnessed cardiac arrest. EMS arrived approx [**6-10**]
minutes later and noted the patient to be in VFib. She was
intubated, shocked three times with return of rhythm to AFib.
She was loaded with 300mg IV amiodarone, started on dopamine,
and transported to [**Hospital3 **] Hospital.
.
In the [**Hospital3 **] ED she arrived intubated but not sedated, and
had no spontaneous movements. EKG demonstrated AFib with STE in
AVL and V6 with diffuse ST depressions. Labs were notable for
tropI 4.42, CK-MB 71, glu 297, AST 165, ALT 89. She was given
325mg rectal ASA, 600mg plavix per the NGT, 80mg atorvastatin,
and started on a heparin gtt.
.
She was taken to the cath lab but went into polymorphic VT
without a pulse prior to the cath, requiring 5 shocks and an
additional 150mg IV amiodarone. The VT resolved and she was
cooled via Arctic Sun. They proceeded with the right heart cath
via a right groin approach which revealed a PASP of 42 and mean
wedge pressure of 22. Her SBP fell to the 60s and she was
started on phenylephrine. They then proceeded with the left
heart cath which demonstrated 3-vessel disease (LAD with 60-70%
ostial stenosis with diffuse 40% proximal stenosis and 50%
mid-disease; LCx with diffuse 60% proximal stenosis with a small
OM2 that was 100% occluded but filled well by bridging
collaterals; RCA with diffuse 50% proximal stenosis with a 90%
mid-lesion and TIMI-3 flow; there was no obvious plaque rupture
or thrombotic occlusion so no PCI was performed). A balloon pump
was placed. She remained unresponsive with SBP in the 120s.
.
She is currently on dopamine, phenylephrine, heparin gtt, and
amiodarone gtt. She is being transferred to [**Hospital1 18**] for further
post-arrest treatment and possible CABG. Per report, she has had
no further arrhythmias following the second arrest.
.
ROS: Unable to obtain
Past Medical History:
- Atrial fibrillation on coumadin
- History of rheumatic heart disease
- Mild dementia
Social History:
unable to obtain
Family History:
unable to obtain
Physical Exam:
Hemodynamically stable on admission. Intubated, no
vestibulo-ocular reflex, fixed and dilated pupils. No elevated
JVD. Lungs coarse bilaterally. S1/S2 unable to be heard. ABd
soft NT ND. No BLE edema. Arctic sun on abdomen and thighs. PA
catheter and IABP in R groin appear well placed. Foley in place.
Body is cool. Does not withdraw to pain.
Pertinent Results:
LABS (OSH):
Na 137, K 3.4, Cl 102, HCO3 22, BUN 34, Creat 1.1, Glu 297, Ca
9.4, AST 165, ALT 89, TBili 1, DBili 0.3, Alk Phos 71, Lipase
47, TropI 4.42, CK-MB 71.1, CK 360, Tot Prot 6, Albumin 3,
.
IMAGING: none
.
PROCEDURES ([**2160-10-2**]):
Right Heart Cath ([**Hospital3 **]):
RA: a wave 12, v wave 13, mean 10
RV: 40/11
PA: 40/21
PCW: a wave 22, v wave 32, mean 22
AO: 65/43, mean 53
SVC O2 59%
Left PA O2 59%
.
Left Heart Cath ([**Hospital3 **]):
3-vessel disease. LAD with 60-70% ostial stenosis with diffuse
40% proximal stenosis and 50% mid-disease. Left circumflex with
diffuse 60% proximal stenosis with a small OM2 that was 100%
occluded but filled well by bridging collaterals. RCA with
diffuse 50% proximal stenosis with a 90% mid-lesion and TIMI-3
flow. There was no obvious plaque rupture or thrombotic
occlusion so no PCI was performed.
.
See OMR for [**Hospital1 18**] labs
Brief Hospital Course:
Briefly, 80yoF was seen to have cardiac arrest this am. EMS
resuscitated her with defibrillation, intubated her, and took to
her [**Hospital3 417**] Hospital where she was not responsive. EKG
showed STEMI in aVL and V6, and she had positive cardiac
enzymes, she was given ASA, Plavix, statin, Heparin gtt. She
went to cath lab, had more episodes of VTach pulseless, was
shocked numerous times, started cooling protocol, and was cathed
which did not clearly show any culprit lesion, see below, there
was no PCI performed. Balloon pump was placed, she was
transferred to [**Hospital1 18**] on Dopamine gtt, Neo gtt, Amiodarone gtt,
and Heparin gtt.
On arrival here she was initially hemodynamically stable,
unresponsive, pupils were fixed and dilated, there was no
vestibule-ocular reflex, she did not withdraw to pain, had no
gag reflex to the ET tube despite no sedation, heart sounds were
extrememly difficult to hear, lungs rhonchorous, RIJ in place,
aortic balloon catheter in RFA and PA cath in RFV. She was being
cooled.
Over the next several hours, we stopped the Phenylephrine gtt
and started Levophed instead and weaned the Dopamine gtt from 25
(which is above recommended dosages) down closer to 10. We
started Fentanyl/Versed/Cisatracurium. The cardiac arrest /
cooling protocol team was made aware. We reviewed the cath films
with attending and fellow.
As an arterial line was attempted, the pt had the first of what
would be innumerable episodes of VTach and VFib. Over the next
1-2 hours, the pt was shocked literally at least 15-20 times,
and had several rounds of 1mg Epinephrine, 1mg Atropine x2,
several rounds of calcium, magnesium, several amps of HCO3, and
potassium when she was noted to be low. She was started on a
Lidocaine gtt at 2 mg/min, and was given Amiodarone 300 mg then
later 150 mg. An initial ABG showed her to have metabolic
acidosis and her lactate climbed from 4 to 8 over the hours.
Levophed was running throughout and Dopamine as well except a
brief period that it was stopped due to rebound tachycardia from
Epinephrine. An arterial line was placed in the left during the
code.
Finally the family arrived including the pt??????s husband, sister,
and several other family members; it was quickly decided to call
the code. She was in VFib when they arrived and passed away very
quickly afterwards. Her time of death was 350pm. Our deepest
condolences were expressed to the family and we explained that
we did the most that we could do to keep her alive. They were
appreciative and declined autopsy. The medical examiner declined
the case.
Medications on Admission:
Aricept
Discharge Medications:
N/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Cardiac arrest with cooling likely from STEMI
Discharge Condition:
Expired
Discharge Instructions:
N/a
Followup Instructions:
N/a
|
[
"42731",
"V5861"
] |
Admission Date: [**2193-8-3**] Discharge Date: [**2193-8-22**]
Date of Birth: [**2172-1-21**] Sex: F
Service: NEUROLOGY
Allergies:
Compazine
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
fever, nausea/vomiting, joint and neck pain, seizures
Major Surgical or Invasive Procedure:
multiple lumbar punctures
Continuous EEG monitoring
History of Present Illness:
Ms. [**Name13 (STitle) **] is a 21 yo F with h/o mixed connective tissue
disorder who is transferred to [**Hospital1 18**] ED from LGH ED for workup
of
fever, nausea/vomiting, joint and neck pain, and 2 seizures
yesterday. Her story is relayed by her boyfriend and family as
patient is too confused to provide a history.
.
Patient was in her usual state of health until one week ago,
when
she spiked a fever to 103.7. She went to [**Hospital 83634**] Hospital,
where she was given IV fluids, Tylenol and Compazine for nausea
(which incidentally caused dystonic reaction). The following
day,
she was febrile to 100.7; this time it was associated with
nausea, vomiting, and diffuse arthralgias and myalgias which
were
also present in her neck. Over the next two days, her
nausea/vomiting, fevers and diffuse arthralgias/myalgias
persisted, and she also became quite somnolent and slept for >20
hours per day.
.
Yesterday morning when she awoke at ~6:30 AM, her boyfriend
noted
she was quite lethargic and speaking in broken phrases, not
making any sense (e.g. would say "go to the garage" completely
out of context to the conversation). She also had several
episodes of "going blank" where she would be completely
unresponsive. At 12 PM she had a 1 minute long episode of
unresponsiveness during which her left hand opened and closed
repeatedly (likely partial complex seizure). During this episode
her pupils constricted and dilated repeatedly and her eyes
twitched back and forth rapidly. She was also completely
confused, and per her family was completely amnestic to all
events within the past 4 weeks.
.
Of note, patient has had multiple potential infectious exposures
lately, including countless mosquito and flea bites. She has 2
new cats, and also helps out at a horse barn. She went canoeing
for a week in [**State 1727**] earlier in [**Month (only) 216**], during which time her
boyfriend had a one-day episode of nausea, vomiting and migraine
headache. For other sick contacts, her mother had a ?viral URI
one week ago. No known unusual ingestions recently. She is
sexually monogamous with her boyfriend.
.
Her family brought her to [**Hospital6 3105**] after this
episode yesterday, where she was febrile to 101.0 on arrival. On
her way to CT scanner, she became agitated, started vomiting,
and
had a 2-minute episode where her eyes rolled back in her head
and
all over her extremities shook violently (likely generalized
tonic-clonic seizure). Afterwards she had a 20-minute post-ictal
period where she was somnolent and confused. Her NCHCT at LGH
was
negative per report. An LP was performed which showed <1000 RBCs
in both bottles, 13 WBCs (48% PMNs), protein 54*, and normal
glucose. She received dilantin load (unknown dose), ceftriaxone
2grams IV, acyclovir 800mg IV, and was transferred to [**Hospital1 18**] for
further workup.
.
On arrival to [**Hospital1 18**] ED, vitals were 99.0 78 107/73. While in the
ED she spiked to 101.1. She had multiple episodes of blank
staring and unresponsiveness which I witnessed while taking her
history. In between these episodes she was awake and alert but
very confused. She knew her name and recognized her family
members but did not know where she was and thought the ED
curtain
was a shower curtain. The episodes of unresponsiveness became
more and more frequent in the ED, and were spaced <8 minutes
apart right before she was transported upstairs.
.
Neurologic ROS is otherwise negative except for above. General
ROS is positive for dry cough. Also positive for heavy vaginal
bleeding at LGH (noted by mom), unusual given that LMP ended one
week ago. No chills, night sweats, recent weight gain/loss,
palpitations, diarrhea, dysuria, or rashes.
.
Past Medical History:
PAST MEDICAL HISTORY:
- Mixed connective tissue disorder (characterized by joint
aches/pains/swelling. Followed at [**Hospital3 1810**] [**Location (un) 86**].
Was on prednisone + MTX in past
Social History:
Lives with boyfriend in [**Name (NI) 1157**] MA. In college part-time but
worked in a gardening shop. Marijuana 2x/wk. Social alcohol.
Denies tobacco, heroine, cocaine, and other IVDU. Denies
domestic violence or sexual abuse.
Family History:
- Mother: Hypothyroidism, Ovarian cysts (?PCOS), Cholecystectomy
- Father: Inflammatory arthritis (?Rheumatoid), B12 deficiency,
Restless leg syndome, A-fib, [**Doctor Last Name 933**] (in remission),
Cholecystectomy
- Mother's parents: heart disease, alcoholism
- Paternal grandmother: [**Name (NI) 83635**]
Physical Exam:
Exam on admission:
Vitals: 101.1 78 107/73
General: pale but non-toxic appearing young F in NAD, WD/WN,
looking expressionlessly around room.
HEENT: NC/AT. MMM. No oral lesions.
Neck: Supple, no LAD. Subjective discomfort with neck flexion
but
no Kernig/Brudzinsky sign.
Pulm: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended, +BS, no HSM/masses
Extremities: WWP, no C/C/E, pulses 2+ bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: AAOx1 (person, not place or time). Flat affect.
Unable to relate history, responds "I don't know" in response to
almost all questions. Can say DOW forward with some prompting,
cannot say DOW backward. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Pt. was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects, but could recall
0/3 at 3 minutes, even with prompting. No knowledge of current
events. No evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 4mm and brisk. VFF to confrontation. Funduscopic
exam without papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI with fast-beating nystagmus on resting
position
and in all directions. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch throughout.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 3 3 2
R 3 3 3 3 2
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: not tested in setting of multiple ?seizures
Physical exam [**2193-8-19**]:
PHYSICAL EXAM:
Gen: NAD, comfortable
Resp: breathing comfortably
VS T: AF, 98.4 HR: 93 (93-125) BP: 106/81 RR: 20 SaO2: 99%
General: NAD, lying in bed comfortably.
- Respiratory: Nonlabored
- Skin: Multifocal rash in areas that can be reached by
patient's
hands, pale base with erythematous rim consistent with
excoriations
Neurologic Examination:
- Mental Status: Awake, alert, oriented to being at [**Hospital1 **]. Minimal
recall of recent events. Has learned the names of 2 residents
that she has seen repeatedly but does not learn name of medical
student after repeated coarching.
MOCA performed again (see chart); 21/30 (points deducted for
clock hand placement; fluency: 7 words starting with S with 4
words each repeated 3-4 times; when provided with explicit
instructions not to repeat words, named 6 words starting wtih B
with 2 repetitions; spontaneous recall [**1-13**] improving to [**2-11**] with
category cueing and [**3-14**] with list cueing); Language fluent
without dysarthria and with verbal comprehension. No paraphasic
errors. Normal prosody. No dysarthria. Good ideomotor praxis.
Normal performance on simple executive function tests, including
Luria hand sequencing and go-no go test. On animal fluency test,
named 9 animals with 10 repeats.
On hand movement mirroring, good performance with only one
right/left confusion error.
[**Last Name (un) **] Complex Figure performed: slowed but intact copy of figure.
Delayed recall: did not recall having drawn figure, when
prompted
drew a square.
See attached for drawing.
Cranial Nerves: [II] VF full to number counting. Funduscopy
shows
crisp disc margins, no papilledema. [III, IV, VI] EOM intact, no
nystagmus. Normal saccades [V] V1-V3 without deficits to light
touch bilaterally. Pterygoids contract normally. [VII] No facial
asymmetry. [VIII] Hearing intact to voice. [IX, X] Palate
elevation symmetric. [[**Doctor First Name 81**]] SCM strength 5/5 bilaterally. [XII]
Tongue midline.
Motor: Normal bulk and tone. No pronation or drift. No tremor or
asterixis.
[Delt] [Bic] [Tri] [ECR] [FF] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[[**Last Name (un) 938**]] [EDB]
L 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
Sensory: No deficits on stereognosis, graphesthesia, topognosis,
direction sensing. Intact warm/cold temperature discrimination.
Reflexes
=[Bic] [Tri] [[**Last Name (un) 1035**]] [Quad] [Ankle]
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response extensor bilaterally.
Coordination: mildly ataxic on rebound, finger-to-nose, finger
mirroring, and heel-knee-shin testing. Dysdiadochokinesia of
left
but not right hand.
Gait: hesitant initiation. wide base, very unsteady, unable to
take even one or two steps without support.
Unstable stance with feet together with eyes open and close.
Exam on discharge:
VS: AF 98.5F, BP 98/68, HR 89-133, RR 16, O2sat 100%RA
Gen: NAD, comfortable, affect cheerful
Derm: still with multifocal excoriated rash, lesions with
central pallor and red rim, also multiple erythematous papules
around mouth
CV: Tachy but regular
Pulm: breathing nonlabored
Abd: scaphoid, normal bowel sounds, no
tenderness/rigidity/guarding
Mental status: alert, oriented to self & place, registered [**3-13**]
words and recalled [**2-10**] spontaneously and [**3-13**] with category
cueing
CN: PERRL 9->4mm brisk, visual fields full, EOM intact
w/end-beat nystagmus, good smooth pursuit, face/jaw
opening/palate elevation symmetric, tongue midline & moves
easily, SCMs strong
Motor: no pronator drift, full strength in upper & lower
extremities proximally & distally in flexors & extensors
Coordination: no rebound
Sensation: intact to fine touch in extremities
Gait: continues to be impaired
Pertinent Results:
IMAGING:
- CT HEAD W/O CONTRAST; OUTSIDE FILMS READ ONLY [**2193-8-3**] 2:28
AM: Study limited by technique. Within this limitation no acute
intracranial pathology. Please note that MRI is more sensitive
for the detection of encephalitis and discrete masses and may be
considered if there are no contraindications to the use of MRI
and if this is clinically warranted.
- MR HEAD W & W/O CONTRAST [**2193-8-3**] 2:55 PM:
FINDINGS: There is slight increase in signal within both
hippocampi without
enhancement or mass effect. No evidence for acute ischemia or
hydrocephalus.
No pathologic enhancement.
The cerebellar tonsils are somewhat low lying, which may be in
the spectrum of
Chiari malformation.
Flow voids are maintained.
IMPRESSION:
Slight increase in signal within both hippocampi, which can be
seen as a
post-ictal phenomenon, but possibility of viral encephalitis
cannot be
entirely excluded. Clinical correlation is advised.
The cerebellar tonsils are somewhat low lying, which may be in
the spectrum of
Chiari malformation.
- EEG [**8-3**]: IMPRESSION: This telemetry captured no pushbutton
activations. The background
is generally disorganized in wakefulness but included some alpha
frequencies.
There were very frequent left anterior quadrant spike and sharp
wave
discharges, particularly during sleep. There were no rapidly
recurrent
discharges or electrographic seizures.
- PELVIS, NON-OBSTETRIC; PELVIS U.S., TRANSVAGINAL [**2193-8-5**] 3:01
PM: Normal-appearing left and right ovaries, with incidental
note of small
amount of free fluid in the pelvis and around the right ovary
- EEG [**8-5**]:
IMPRESSION: This is an abnormal continuous video EEG recording
with diffuse
background slowing, focal slowing over right and left temporal
and right
central regions with admixed sharp features, sharp transients
and sharp and
slow wave interictal discharges seen. There were no clear
electrographic
seizures observed on this day's recording. This day's recording
demonstrates
improvement from prior days' recording.
- EEG [**8-6**]:
IMPRESSION: This is an abnormal continuous video EEG recording
with diffuse
theta background slowing, focal R>L delta slowing in central and
temporal
regions with admixed sharp features, sharp trnasients and sharp
and slow wave
interictal discharges seen. There were no clear electrographic
seizures
observed on this day's recording.
- TTE [**8-7**]: Findings
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). TDI E/e' < 8,
suggesting normal PCWP (<12mmHg). Doppler parameters are most
consistent with normal LV diastolic function. No resting LVOT
gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Mild MVP. Late systolic MR jet. Mild (1+) MR.
Normal LV inflow pattern for age.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Very small pericardial effusion.
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Doppler
parameters are most consistent with normal left ventricular
diastolic function. Right ventricular chamber size and free wall
motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) appear structurally normal with good leaflet excursion and
no aortic stenosis or aortic regurgitation. There is mild
bileaflet mitral valve prolapse. A late systolic jet of Mild
(1+) mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is a very small
pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Normal diastolic function. Mild mitral valve prolapse
with mild mitral regurgitation.
- EEG [**8-7**]:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of
the presence of a diffuse background slowing compatible with a
diffuse
encephalopathy affecting predominantly cortical neuronal
systems. There is
superimposed multifocal delta slowing suggesting potential
multifocal cortical
injury with occasional sharp and potential epileptic sharp
activity. There
were no clear electrographic seizures.
- EEG [**8-9**]:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of
moderate diffuse background slowing, slow alpha rhythm, and runs
of frontal
intermittent rhythmic delta activity. These findings are
indicative of
moderate diffuse cerebral dysfunction, which is etiologically
nonspecific.
FIRDA can be seen in metabolic encephalopathies, as well as
increased
intracranial pressure, hydrocephalus, and deep midline
structural lesions.
There are no epileptiform discharges or electrographic seizures
recorded. Of
note, the patient has sinus tachycardia throughout the
recording. Compared to
the prior day's recording, there are no significant changes.
CTA [**8-9**]
FINDINGS: The thoracic aorta is normal in caliber without
evidence of
dissection. The pulmonary arterial vasculature is well
visualized to the
subsegmental level without filling defect to suggest pulmonary
embolism. No
pathologically enlarged axillary, mediastinal, or hilar lymph
nodes are
identified. The heart and great vessels are within normal
limits without
evidence of right heart strain. A tiny pericardial effusion is
of no
hemodynamic significance. A central venous catheter ends in the
region of the
cavoatrial junction. A nasogastric tube is in the esophagus.
Soft tissue
density in the anterior mediastinum is thymic tissue in this
young patient.
There is no pleural effusion.
Lung window images demonstrate no worrisome nodule, mass, or
consolidation.
Note, the upper lung zones and lung bases are not imaged.
Airways are patent
to the subsegmental levels bilaterally.
The study is not tailored for subdiaphragmatic evaluation, but
the imaged
portion of the liver is normal.
BONE WINDOWS: No bone finding suspicious for infection or
malignancy is seen.
IMPRESSION: No acute aortic pathology or pulmonary embolism.
EEG [**8-10**]:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of
moderate diffuse background slowing, slow alpha rhythm, and runs
of frontal
intermittent rhythmic delta activity. These findings are
indicative of
moderate diffuse cerebral dysfunction, which is etiologically
nonspecific.
FIRDA can be seen in metabolic encephalopathies, as well as
increased
intracranial pressure, hydrocephalus, and deep midline
structural lesions.
There are no epileptiform discharges or electrographic seizures
recorded.
Sinus tachycardia is present throughout the recording. There are
10
pushbutton events, but no clear clinical or EEG change during
these episodes.
Compared to the prior day's recording, there are no significant
changes.
MRI Brain [**8-10**]:
Final Report
Noted is diffuse FLAIR-hyperintensity in the sulci of both
cerebral as well as
the cerebellar hemispheres. This is likely "spurious,"
reflecting high FIO2
(inspired oxygen concentration), as according to the MR
[**Name13 (STitle) 83636**] note,
and confirmed in conversation with Dr. [**Last Name (STitle) **], this study was
performed under
general anesthesia with supplemental oxygen. Along these lines,
there is no
pathologic leptomeningeal or dural focus of enhancement.
However, there are now relatively symmetric multifocal
parenchymal signal
abnormalities, as follows: There is confluent
T2-/FLAIR-hyperintensity with
corresponding T1-hypointensity involving both cerebellar
hemispheres, left
more than right, completely new. There is also now more
confluent
T2-/FLAIR-hyperintensity involving the medial temporal lobes
including the
entirety of the hippocampal formations and parahippocampal gyri,
with gyral
swelling. This process is far more extensive than on the
previous study.
However, there is also now similar signal abnormality involving
the lateral
aspect of the left temporal lobe, while there is a more discrete
rounded 11 mm
signal abnormality in the mid-right temporal lobe, just anterior
to that
petrous apex. Finally, less extensive and hyperintense paired
signal
abnormalities are seen in the immediate subcortical white matter
of the right
frontovertex and paramedian posterior parietal lobes. Of note,
none of these
abnormalities demonstrates a corresponding abnormality of
diffusion or
pathologic enhancement. There is no associated susceptibility
artifact to
suggest hemorrhage, either at these sites or elsewhere in the
brain. Finally,
there is no involvement of the deep [**Doctor Last Name 352**] matter structures of
the internal
capsule or thalamus, and the immediate periventricular white
matter as well as
the mid brain and brainstem also appear spared.
Again demonstrated is marked cerebellar tonsillar descent, at
least 16 mm
caudal to the plane of the foramen magnum, with a "peg-like"
morphology.
There is accompanying crowding at the foramen with slight
angulation of the
cervicomedullary junction. These findings are suggestive of
underlying Chiari
I malformation, unrelated to the process, above. There is no
evidence of
central herniation. There is no space-occupying lesion, and the
sella,
parasellar region and remainder of the skull base are
unremarkable. The
orbits are unremarkable, and the mastoid air cells and included
paranasal
sinuses are clear.
The principal intracranial vascular flow-voids, including those
of the dural
venous sinuses, are preserved and these structures enhance
normally. There is
normal flow-related enhancement in the included intracranial
portions of both
internal carotid and proximal middle and anterior cerebral
arteries,
bilaterally, there is normal, symmetric arborization of MCA
branches, without
significant mural irregularity or flow-limiting stenosis. There
is normal
flow-related enhancement in the distal vertebral arteries, with
dominant left
vessel, and in the basilar and bilateral superior cerebellar and
posterior
cerebral arteries, without significant mural irregularity or
flow-limiting
stenosis. Anterior and robust posterior communicating arteries
are
identified, with no aneurysm larger than 3 mm. Incidentally
noted is a
so-called "patulous" basilar summit with conjoined origins of
the SCAs and
PCAs, bilaterally.
IMPRESSION: Markedly abnormal study, which has significantly
progressed since
the recent examination of [**2193-8-3**], including:
1. Symmetric signal abnormalities involving both cerebellar
hemispheres and
medial temporal lobes, the latter involving the limbic circuit,
without
enhancement, hemorrhage or diffusion abnormality. In this
clinical setting,
these findings suggest evolving severe limbic and
rhombencephalitis.
2. There is also symmetric involvement of the
fronto-parietovertex, as well
as the lateral aspect of the left temporal lobe with sparing of
the deep [**Doctor Last Name 352**]
matter structures and the brainstem; while these findings may
reflect more
widespread involvement by the process in #1, above, they also
might reflect
the development of secondary PRES.
3. No evidence of central herniation.
4. Diffuse and uniform abnormality of the subarachnoid space,
also new;
however, this is likely "spurious" and related to study
acquisition during
high-flow oxygen therapy. Use of 100% O2 during the examination
has been
confirmed by Dr. [**Last Name (STitle) **], on review of more detailed notes by the
anesthesia
service.
5. Underlying Chiari I malformation, with no finding to
specifically suggest
syringohydromyelia involving the limited included upper cervical
spinal cord;
however, this would be better assessed with dedicated cervical
spine study, MR
study, on an elective basis.
6. Unremarkable cranial MRA, with no flow-limiting stenosis,
evidence of
vasculopathy or aneurysm larger than 3 mm.
CT abdomen/pelvis [**8-11**]:
FINDINGS:
ABDOMEN: The lung bases demonstrate minimal dependent
atelectasis. No
pleural or pericardial effusion is seen. The liver, spleen,
gallbladder,
pancreas, adrenal glands, kidneys, visualized portions of the
ureters,
stomach, small bowel, colon, and appendix demonstrate no acute
abnormalities.
Mild focal fatty infiltration in the liver about the enlarged
mesenteric or
retroperitoneal lymphadenopathy is detected. An enteric
catheter courses into
the proximal duodenum. Visualized intra-abdominal vasculature
is
unremarkable.
PELVIS: The bladder, uterus, adnexa, and rectum are within
normal limits.
Trace free fluid is seen in the pelvis, as seen on recent pelvic
ultrasound.
No enlarged intrapelvic or inguinal lymphadenopathy is detected.
No concerning lytic or sclerotic osseous lesions are detected.
IMPRESSION:
1. No CT evidence for intra-abdominal or pelvic malignancy.
2. Interval migration of enteric catheter into the proximal
duodenum.
EEG [**8-11**]:
IMPRESSION: This is an abnormal continuous ICU monitoring study.
The
background activity is slow mostly in theta and delta range,
with frequent
brief runs of frontal intermittent rhythmic delta activity
(FIRDA), suggestive
of moderate encephalopathy. There are seven patient pushbutton
events for
body jerks; none are associated with any change in EEG
background. There are
no epileptiform discharges or electrographic seizures recorded.
Compared to
the prior day's recording, there is no significant change.
EEG [**8-12**]:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of
moderate diffuse background slowing and runs of frontal
intermittent
semirhythmic delta activity. These findings are indicative of
mild to
moderate diffuse cerebral dysfunction which is etiologically
non-specific. No
electrographic seizures are present. Compared to the prior day's
study, there
is no significant change.
Skin, right flank; punch biopsy (A): [**2193-8-15**]
1.Focal parakeratosis with occasional dyskeratosis, mild
spongiosis and very sparse superficial perivascular lymphocytic
infiltrate (see comment).
2.No bacterial organisms seen on a tissue Gram stain.
3.No fungal organisms seen on PAS and GMS stains.
4.No mycobacteria seen on an AFB stain.
5.No herpes virus seen in multiple tissue levels examined or on
an HSV-specific immunostain.
Comment. There is also focal upper dermal red blood cel
extravasation and mild vascular ectasia. The findings in this
biopsy are not well developed nor are they specifically
diagnostic. They are compatible with a viral exanthem in the
appropriate clinical setting, and the histologic differential
diagnosis also includes a hypersensitivity reaction such as to a
drug although per clinical discussion this is not favored.
Brief Hospital Course:
21F with history of mixed connective tissue disorder now in
remission presents with 1 week history of fevers and worsening
fatigue. Tmax at home to 103.7, went to OSH ED diagnosed with a
viral illness and sent home with tylenol and compazine after IVF
hydration. Patient had a dystonic reaction which was attributed
to prochlorperazine, she was brought back to the ED and given
benadryl and more IVF and sent home. She had worsening fatigue,
lethargy, nausea, vomiting, and ongoing fevers at home. [**8-2**]
began acting strangely, with loss of short-term memory,
confusion, and increasing neck pain. She also had episodes of
"spacing out" and repetitive bilateral finger/hand movements.
Had witnessed generalized tonic/clonic seizure at OSH ED and was
given phenytoin. LP performed was significant for elevated
protein and CT head negative for bleed. Empiric abx was started
for meningitis, and she was transferred to [**Hospital1 18**] for further
workup and management. She transfered to ICU as her symptoms
were concerning for HSV encephalitis.
#######First ICU course:
During the 2-day ICU stay, Infectious Disease was consulted due
to multiple potential exposures to infectious agents that can
cause encephalitis, including arboviruses and Bartonella. In
addition, EBV or HSV could cause a similar picture and MRI
showed hyperintense areas in both hippocampi. She was started on
vancomycin 1g IV, ceftriaxone 2 gm IV Q 12H, doxycycline 100 mg
IV Q12H, rifampin 300 mg IV Q12H and acyclovir 10 mg IV Q8H as
empiric therapy for infectious encephalitis on [**8-3**]. Vancomycin
was discontinued on [**8-3**] and ceftriaxone was discontinued on
[**8-6**] due to low suspicion of bacterial meningitis. To control
seizure activity, phenytoin was changed to levetiracetem 750 mg
[**Hospital1 **] on [**8-4**], but dose was increased to 1000mg [**Hospital1 **] and 1500mg
[**Hospital1 **] on [**8-5**] and 2000mg on [**8-6**].
Due to history of MCTD and concern for autoimmune limbic
encephalitis, she was started on methylprednisolone 1 gram iv on
[**8-4**] for total of 4 days. She was transferred to the Neurology
floor for further work-up. At the time of transfer, she was
afebrile but still had problem with short term memory.
- [**8-7**]: Polymorphic VT with low K, Mg, Ca. Discontinued
metoclopromide and ondansetron due to concern for QT
prolongation
- [**8-8**]: 15 minute generalized seizure. 2g Lorazepam given
##########Second ICU cource:
in ICU she did not develope seizure, she had sinus tachicardia
and was on propranolol in that regard .
- she did not develope fever.
- The result for VZV and HSV came back negative, but ID wanted
to continue gancyclovir and negative pressure isolated room
- As her status remained stable she was transfer to floor on
[**2193-8-14**].
- At the time of transfer she still had problem with short term
memory and she was disoriented to time. No focal deficit was
found in motor, sensory or cranial nerve.
##########################
After transfer back to floor:
ASSESSMENT:
# NEURO:
21F with history of mixed connective tissue disorder thought be
in
remission, who presented with fatigue, disorientation, amnesia
and seizures concerning for limbic encephalitis; this developed
a
week after a prodromal sign of a febrile illness with nausea and
vomiting. At the time of transfer back to floor, she has been
afebrile for > 2 weeks, her seizures are now well controlled on
levetiracetam and lacosamide but she
continued to have dense anterograde and retrograde amnesia
concerning for tissue damage in memory-forming
areas. More recently, she has also developed bilateral ataxia
and gait instability.
The last days of her admission, pt's affect is much more
cheerful than
it has been. There is some evidence that her encoding is
gradually improving but stably moderately poor performance on
sequential MOCAs.
Causes of limbic encephalitis that remain on the differential
include autoimmune vs. paraneoplastic vs infectious (likely
viral). S/p 4-day methylprednisolone 1000 mg burst without
improvement.
- Pertinent positives: temporal EEG spikes & sharp waves, MRI
findings of primarily bilateral temporolimbic involvement.
Patient had repeat MRI on [**8-10**] which suggested progressive severe
limbic and rhombencephalitis with bilateral cerebellar
involvement in addition to worsening in the previously affected
areas.
- Negative/wnl: HIV Ab & RNA, cryptococcal Ag, EBV EBNA + &
IgG+,
Lyme Ab, pelvic U/S and CT torso, dsDNA, C3/4, anti-TPO,
anti-Tg,
serum HSV Ab, CSF HSV PCR, CSF enterovirus PCR, thick & thin
smears for Babesia, Blood parasite smear, anti-[**Doctor Last Name 1968**], anti-Ro,
anti-La, Bartonella henselae & [**Last Name (un) 7570**], HME & HGA, CSF
oligoclonal bands, serum & CSF anti-[**Doctor Last Name **]
- Baseline high [**Doctor First Name **] titers (1:1280), anti-RNP (unchanged
compared
to [**Hospital1 **] values)
#Neuro:
1) Concern about encephalitis
- Finished ganciclovir 14 day course (day 1 = [**8-8**], day 14 =
[**8-21**]) due to concern about possible CNS varicella or HHV6
despite
negative CSF PCRs.
- Still awaiting results of CSF paraneoplastic panel and
anti-NMDA Ab
- Still awaiting results of arbovirus PCR
- The remaining studies can be followed up in outpatient setting
2) Seizures: newest EEGs with encephalopathy but no seizure
activity.
- Continue levetiracetam [**2180**] mg [**Hospital1 **] and lacosamide 200 mg [**Hospital1 **].
Will try to wean off AEDs in outpt setting after repeat EEG in
[**2-12**] months. Prescribing folate 0.8 mg daily supplementation to
prevent NTDs in case of pregnancy.
# ID/RHEUM:
- No signs of infection at time of discharge
#CARDS: had autonomic dysregulation after her last seizure [**8-8**].
Now still w/occasional sinus tach
- Continue propranolol 40 mg TID to dampen sympathetic tone (can
try to wean as outpt)
#GI: Significant nausea & vomiting during this admission,
improved after initiation of tube feeds, indicating that
previous severe nausea/vomiting may have been
secondary to dysosmia and dysgeusia that pt was complaining of.
On exam, dysosmia was replicated and smell testing elicited
nausea. Now still w/decreased but improving PO intake.
#DERM: Multifocal rash with differential of atypical-appearing
VZV vs contact dermatitis vs secondary to scratching from
neuropathic pruritus. Derm biopsy nonspecific, viral studies
negative. Per family, itching precedes rash, and there is no
rash until patient scratches, making neuropathic pruritus
leading w/secondary prurigo a distinct possibility.
- continue diphenhydramine 25 mg PO q8h PRN itching and
gabapentin 300mg in am and at noon and 400 mg qhs for possible
neuropathic pruritus
- Topically, continue pramoxine 1% up to five times daily.
- PRN cold packs
- Pt has derm follow up next week
#HEME: Normocytic anemia, now resolved.
Medications on Admission:
Ibuprofen PRN pain
Discharge Medications:
1. DiphenhydrAMINE 25 mg PO Q6H:PRN Nausea
RX *diphenhydramine HCl 25 mg 1 tablet(s) by mouth as needed, up
to every 6 hours Disp #*60 Tablet Refills:*0
2. Lacosamide 200 mg PO BID
RX *lacosamide [Vimpat] 200 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
3. LeVETiracetam [**2180**] mg PO BID
RX *levetiracetam 1,000 mg 2 tablet(s) by mouth twice daily Disp
#*120 Tablet Refills:*0
4. Ondansetron 4 mg PO Q8H:PRN Nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth as needed, up to every
8 hours Disp #*45 Tablet Refills:*0
5. pramoxine *NF* 1 % Topical Five times daily as needed (PRN)
pruritic rash Reason for Ordering: Recommended by dermatology
consultants
RX *pramoxine [Sensitive Anti-Itch] 1 % apply to affected itchy
areas up to five times daily as needed Disp #*1 Tube Refills:*1
6. Propranolol 40 mg PO TID HR > 120
Hold for SBP<100, hr<60
RX *propranolol 40 mg 1 tablet(s) by mouth three times daily
Disp #*90 Tablet Refills:*0
7. Sarna Lotion 1 Appl TP TID:PRN pruritus
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % apply to
affected itchy areas up to three times daily Disp #*1 Tube
Refills:*1
8. Gabapentin 300 mg PO BID
In am and midday
RX *gabapentin 300 mg 1 capsule(s) by mouth in the morning and
at noon Disp #*60 Capsule Refills:*0
9. Gabapentin 400 mg PO HS
RX *gabapentin 400 mg 1 capsule(s) by mouth in the evening Disp
#*30 Capsule Refills:*0
10. FoLIC Acid 0.8 mg PO DAILY
RX *folic acid 0.8 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 **] Hospital [**Hospital1 189**]
Discharge Diagnosis:
Limbic and rhombencephalitis of unknown etiology
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted because you developed confusion, seizures,
memory problems (amnesia), and problems with coordination
(ataxia). These were likely caused by an encephalitis
(inflammation of the brain), specifically attacking the temporal
lobes and cerebellum. This was evident on the MRI of your brain.
You also had inflammatory cells in your spinal fluid.
Although we sent many studies, up to this point we have not been
able to determine what caused your encephalitis. However, some
studies are still pending.
We gave you a 4-day course of high-dose steroids but this did
not help your condition.
We were able to control your seizures with the following
medications: levetiracetam (Keppra) and lacosamide (Vimpat). You
were monitored on EEG for many days, and this showed
epileptiform activity initially; however, newer studies showed
no more epileptiform discharges.
During your hospital stay, you also had significant problems
with tachycardia (i.e., a rapid heart beat). For this, we
prescribed you propranolol 40 mg three times daily. You also had
significant problems with nausea and vomiting, and we gave you
anti-nausea medications to control this. Additionally, we had to
give you nutrition via an NG tube for some time. Some of this
nausea was probably caused by abnormal smell function because
you were better able to tolerate foods that went straight into
your stomach, and because you misidentified smells when we
tested them. This gradually resolved.
Another problem that you developed was a widespread itchy rash.
Initially, there was some concern that this could have been
shingles; even though all the studies for this were negative, we
treated you with a 14-day course of ganciclovir for varicella
zoster virus. However, it appears that you develop itching, then
you scratch, and only then do you develop a rash; thus it is
possible that your itching is secondary to the brain
inflammation (neuropathic pruritus).
Followup Instructions:
Provider: [**Name10 (NameIs) **], MD Date/Time: [**2193-8-27**] 1pm. [**Hospital Ward Name 23**] 2
(Dermatology)
Provider: [**Name Initial (NameIs) 21204**] (RHEUM LMOB) [**Last Name (un) **] Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2193-8-28**] 9:30 (Rheumatology)
Provider: [**First Name8 (NamePattern2) 1955**] [**Last Name (NamePattern1) **], MD Date/Time:[**2193-9-18**] 1:30
(Infectious Disease)
Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 43**] & CHWALISZ Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2193-10-21**] 4:30 (Neurology)
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2193-8-22**]
|
[
"2761"
] |
Admission Date: [**2158-10-4**] Discharge Date: [**2158-10-8**]
Service: NEUROLOGY
Allergies:
Morphine
Attending:[**Last Name (NamePattern1) 1838**]
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 89 yo RHW with a prior right temporo-parietal infarct ([**7-30**]), A fib who presents to [**Hospital 2079**] Hospital with left upper
extremity shaking and left arm pain. En route to hospital she
had a generalized seizure. She received 14mg total of ativan for
the seizure + 500 mg Keppra + sedation, intubated to protect
airway, transferred to [**Hospital1 18**] for status epilepticus.
According to her son [**Name (NI) **], who was with her throughout the
episode, they were on their way to pick up rugs at 10 am in a
place in [**Location (un) 577**]. She complained of her left hand feeling numb,
and then of left armpit pain. The EMS were called, and they
arrived around 12:30-1 pm, and she was still coherent in the
ambulance. A few minutes into the ride, her eyes rolled back,
and
her left hand and forearm began to rhythmically move up and
down.
When she got to Southshore, the seizure generalized, and despite
repeated does of Ativan, the seizure did not abort, and so she
was intubated for airway protection.
ROS: unobtainable
Past Medical History:
Right Temporal-Parietal Infarction - left
sided homonymous visual field deficit (went to the [**Hospital3 2358**]
initially)
A fib on Coumadin
Bilateral Total Hip Arthroplasty
Right knee arthroplasty
Lumbar spine fixation x 2
Social History:
Was living independently in [**Location (un) 3844**] until her recent
stroke, now lives in [**Location **], MA with her son. [**Name (NI) **] granddaughter
is [**Name8 (MD) **] RN at the coumadin clinic her at [**Hospital1 18**]. She is a retired
typing and shorthand teacher from a private school. Patient has
two alcoholic drinks per day. She has a distant rare smoking
history. No illicits.Twin sons: [**Name (NI) **] [**Last Name (NamePattern1) **]: [**Telephone/Fax (1) 84599**], [**Doctor First Name 1312**]
[**Telephone/Fax (1) 84600**]
PCP: [**Name10 (NameIs) **] [**Last Name (STitle) **] [**Last Name (NamePattern4) 13959**]
Family History:
Mother- died at age 81
Father- died at age 51 from CAD
Sister- died at age 84 from unclear causes
[**Name (NI) 8765**] died at age 59 from CAD
Son- is alive at age 68, has CAD.
Physical Exam:
T-98 BP-162/86 HR-58 RR-16 O2Sat-100%
Vent settings 450/16/100%/5
Gen: Lying in bed, intubated, on propofol
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Even on propofol, attempting to wake up and bite
the tube.
Cranial Nerves:
Pupils 2 mm bilaterally, sluggishly reactive to light. Dolls
head, corneal reflexes are normal. Facial excursion looks
symmetric. Normal gag response
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
Moves all 4 limbs normally, no asymmetry noted, appears to have
a
right foot drop (chronic)
Sensation: moves all 4 limbs away from noxious stimuli
Reflexes:
+1 in the arms, absent in the legs.
Left Babinski
Coordination & Gait could not be assessed.
Pertinent Results:
Admission labs:
[**2158-10-4**] 04:50PM BLOOD WBC-8.0 RBC-3.94* Hgb-11.8* Hct-36.1
MCV-92 MCH-30.0 MCHC-32.7 RDW-14.9 Plt Ct-209
[**2158-10-4**] 04:50PM BLOOD Neuts-73.2* Lymphs-21.5 Monos-4.4 Eos-0.6
Baso-0.3
[**2158-10-4**] 04:50PM BLOOD PT-27.8* PTT-30.5 INR(PT)-2.7*
[**2158-10-4**] 04:50PM BLOOD Glucose-125* UreaN-23* Creat-0.8 Na-140
K-3.5 Cl-99 HCO3-29 AnGap-16
[**2158-10-4**] 04:50PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2158-10-4**] 04:50PM BLOOD Calcium-9.4 Phos-3.6 Mg-1.2*
[**2158-10-4**] 04:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Radiology Report CT HEAD W/O CONTRAST Study Date of [**2158-10-4**]
6:25 PM
FINDINGS: There is no evidence of acute hemorrhage or shift of
normally
midline structures. The ventricles and sulci are prominent
consistent with
age-related atrophy. There is prior right parietal lobe infarct
with expected
hypodensity. Periventricular white matter hypodensities are
consistent with
chronic small vessel ischemic changes. Right basal ganglia prior
lacunar
infarcts are noted. Calcifications of the bilateral vertebral
arteries as well
as internal carotid arteries, cavernous portions are noted.
There is
otherwise normal [**Doctor Last Name 352**]-white matter differentiation. The basilar
cisterns are
preserved.
The visualized paranasal sinuses are clear.
IMPRESSION:
1. No evidence of acute hemorrhage. Please note that MRI is more
sensitive
in detection of acute ischemia.
2. Extensive chronic small vessel ischemic changes and old right
parietal
infarct.
Brief Hospital Course:
89 yo woman w/Afib and history of recent right temporo-parietal
infarct presenting with seizure. The seizure reportedly started
in her left arm, and then generalized, requiring a large amount
of Ativan to finally break. In that context she was intubated
for airway protection, and transferred to [**Hospital1 18**]. As she had a
history of a stroke in [**Month (only) 216**], and had recently been restarted
on Coumadin, there was some concern that she may have developed
hemorrhagic conversion of her prior stroke, however she had a
head CT with no sign of hemorrhage. She was started on keppra
for prevention of further seizures. She was successfully
extubated on [**10-5**], and after extensive discussion with her
family it was confirmed that her wishes were to be DNR/DNI.
Later that evening she developed increasing respiratory
distress, and a repeat chest x-ray showed near collapse of her
left lung, which was suspected to be due to mucous plugging. At
this time she also became febrile and hypotensive, and was
started on broad spectrum antibiotics. The option of a
bronchoscopy was discussed with the family, however after
extended discussion, it was decided that the patient's wishes at
this time would be to not undergo any further aggressive
intervention, and she was made CMO. She was transferred to the
floor, and passed away on [**10-8**] with her family at the bedside.
Medications on Admission:
AMOXICILLIN - (Prescribed by Other Provider) - 500 mg Capsule -
4 Capsule(s) by mouth once as needed for prior to dental work
take 4 tablets 1 hour prior to dental procedure
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 10 mg
Tablet - 1 Tablet(s) by mouth daily
CONJUGATED ESTROGENS [PREMARIN] - (Prescribed by Other
Provider)
- 0.3 mg Tablet - 1 Tablet(s) by mouth daily
HYDROCHLOROTHIAZIDE - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth daily
IBANDRONATE [BONIVA] - (Prescribed by Other Provider) - Dosage
uncertain
METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 50 mg
Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth daily
SULFASALAZINE - (Prescribed by Other Provider) - 500 mg Tablet
-
1 Tablet(s) by mouth daily
TRAMADOL - (Prescribed by Other Provider) - 50 mg Tablet - 1
Tablet(s) by mouth daily as needed for pain
WARFARIN - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
Tablet(s) by mouth daily
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient was made CMO and passed away
Discharge Condition:
Deceased
|
[
"5180",
"4019",
"2724",
"42731",
"V5861"
] |
Admission Date: [**2161-3-2**] Discharge Date: [**2161-3-4**]
Service: MEDICINE
Allergies:
Percocet / Dilaudid (PF)
Attending:[**Attending Info 11308**]
Chief Complaint:
altered mental status, unresponsiveness
Major Surgical or Invasive Procedure:
Right ventricular lead revision
History of Present Illness:
[**Age over 90 **]-year-old white female with a recent PPM for CHB, history of
CAD, hyperlipidemia, hypertension and arthritis who presented to
[**Hospital6 33**] with altered mental status and failure of
RV capture.
.
Per ED report, the patient had a syncopal episode at her nursing
facility today. The patient just had a pacemaker placed on
[**2161-2-17**] at [**Hospital3 **] after prolonged episodes of complete
heart block with asystole and no escape rhythm. The patient's
family subsequently reports that the patient had been
complaining of some discomfort in the left lower chest/ left
upper abdomen over the past 2 days. They report this is worse
when the patient takes a deep breath.
.
EMS reports that the patient's pacemaker did not appear to be
functioning adequately as they found the patient's heart rate to
be between the 30's and 70's. EMS was not able to obtan IV
access and an IO was placed. There are no reports of any recent
chest pain, shortness of breath, abdominal pain, new back pain,
or trauma. The patient was not able to answer review of systems
questions or identify exacerbating or alleviating factors. The
patient did have some eccymosis about the left side of her head.
.
In the [**Hospital3 **], the patient was successfully intubated with
versed, fentanyl, and succinylcholine out of concerns that she
could not protect her airway and hypotension. A temporary pacing
wire was placed via the right IJ. The patient was bradycardic
and a CXR demonstrated a displaced right ventricular pacer wire.
After consultation with the family, the patient was transferred
to [**Hospital1 18**] for further evaluation and management.
.
At [**Hospital1 18**], we noted complete loss of capture of the pacemaker RV
lead, and intermittent or absent capture of the temporary pacing
wire. During periods of her complete paroxysmal heart block,
she was completely pacer dependent. Given the tenuous
situation, she was taken to the OR emergently. On Echo, there
was concern for RV lead displacement but no evidence of
tamponade or effusion. She was taken to the OR and had the RV
lead repositioned to the RVOT. She was intubated and sedated
and on dopamine. A repeat ECHO demonstrated no effusion or
complication of lead placement. Access is PIV, femoral 7-french
central line.
.
ROS: unable to obtain due to intubation/sedation.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension, diabetes
mellitus
2. CARDIAC HISTORY: CAD. s/p inferior microinfarction
- PACING/ICD: complete heart block s/p pacemaker placement in
[**1-/2161**]
3. OTHER PAST MEDICAL HISTORY:
1. Gastroesophageal reflux disease.
2. Colon cancer.
3. Insulin dependent-diabetes mellitus.
4. History of duodenal ulcer.
5. COPD.
6. Asthma.
7. History of cataracts.
8. Osteoarthritis.
9. History of ventral hernia.
10. History of abdominal wall abscess.
11. Depression.
12. History of colocutaneous fistula.
13. History of diverticulitis.
14. Hyperlipidemia
15. CAD. s/p inferior microinfarction
16. Pulmonary edema, diastolic dysfunction
17. complete heart block.
.
PAST SURGICAL HISTORY:
1. Right colectomy for colon cancer.
2. Ventral hernia repair with mesh.
3. Bilateral hip replacements.
4. Antrectomy and vagotomy with [**Doctor First Name 892**]-[**Doctor Last Name **] II reconstruction with
splenectomy and partial pancreatectomy for duodenal ulcer.
5. Duodenostomy tube.
6. Feeding jejunostomy.
7. Exploration of abdominal abscess.
Social History:
- Tobacco history: ex-smoker
- ETOH: no
- Illicit drugs: no
Family History:
NC
Physical Exam:
VITAL SIGNS: 95.1 60 111/53 100% CMV assist control 400/14
PEEP 5
GENERAL: Intubated w/ RASS of -5.
HEENT: Conjunctiva were pale. Pupils reactive to light. No
xanthalesma.
NECK: Supple with JVP flat
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Pt
intubated CTAB, no crackles, wheezes or rhonchi on anterior lung
exam.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: Intubated with RASS of -5, 2+ reflexes biceps,
brachioradialis, patellar, ankle.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Discharge:
VITAL SIGNS: 98.8 71 110/38 26 99%2L
GENERAL: NAD, AxOx1, agitated.
HEENT: Conjunctiva were pale. Pupils reactive to light. No
xanthalesma.
NECK: Supple with JVP flat
CARDIAC: irregular RR, normal S1, S2. 1/6 systolic flow murmur .
LUNGS: No chest wall deformities, scoliosis or kyphosis. Pt
intubated CTAB, no crackles, wheezes or rhonchi on anterior lung
exam.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
LABS ON ADMISSION:
[**2161-3-2**] 04:30PM BLOOD WBC-15.7* RBC-3.39* Hgb-10.1* Hct-30.8*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.1 Plt Ct-232
[**2161-3-2**] 04:30PM BLOOD Neuts-83.7* Lymphs-11.3* Monos-3.7
Eos-0.9 Baso-0.4
[**2161-3-2**] 04:30PM BLOOD Plt Ct-232
[**2161-3-2**] 04:30PM BLOOD Glucose-103* UreaN-49* Creat-1.7* Na-145
K-5.3* Cl-117* HCO3-22 AnGap-11
[**2161-3-2**] 04:30PM BLOOD CK(CPK)-89
[**2161-3-3**] 04:38AM BLOOD Calcium-8.1* Phos-5.3* Mg-1.8
[**2161-3-2**] 04:21PM BLOOD Type-ART Rates-16/ Tidal V-400 PEEP-5
FiO2-100 pO2-472* pCO2-35 pH-7.36 calTCO2-21 Base XS--4
AADO2-206 REQ O2-43 Intubat-INTUBATED Vent-CONTROLLED
.
LABS ON DISCHARGE:
[**2161-3-4**] 04:22AM BLOOD WBC-12.3* RBC-2.88* Hgb-8.8* Hct-26.3*
MCV-92 MCH-30.6 MCHC-33.5 RDW-14.5 Plt Ct-191
[**2161-3-4**] 04:22AM BLOOD Plt Ct-191
[**2161-3-4**] 04:22AM BLOOD Glucose-93 UreaN-41* Creat-1.6* Na-145
K-4.3 Cl-116* HCO3-22 AnGap-11
[**2161-3-4**] 04:22AM BLOOD Calcium-7.8* Phos-4.2 Mg-2.9*
[**2161-3-3**] 01:25AM BLOOD Lactate-1.1
[**2161-3-3**] 01:25AM BLOOD O2 Sat-98
[**2161-3-3**] 01:25AM BLOOD freeCa-1.14
.
[**2161-3-3**]
pCXR
IMPRESSION:
1. ETT approximately 1.7cm above the carina and should be
repositioned.
2. New right ventricular lead projects medial to the ventricular
apex, however it's exact position cannot be completely assessed
without a lateral view.
.
[**2161-3-2**]
pCXR
FINDINGS: In comparison with the study of [**3-2**], the new right
ventricular lead appears to be in good position, substantially
less peripheral than on the previous study. Endotracheal tube
tip lies approximately 2 cm above the carina. Small layering
pleural effusion persists on the left and there is mild
bilateral basilar atelectasis.
.
ECHO [**2161-3-2**]
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The right ventricular pacing lead is identified in the right
ventricular cavity. It does not appear to extend beyond the free
wall (but images are focused). There is a trivial pericardial
effusion with no echocardiographic signs of tamponade.
.
Compared with the prior study of earlier in the day, the right
ventricular pacing lead no longer appears to extend beyond the
free wall (though views are focused).
.
ECHO [**2161-3-1**]
Normal right ventricular cavity size and free wall motino. In
some views (clips [**4-7**]), the right ventricular pacing lead
appears to extend beyond the right ventricular free wall. There
is no pericardial effusion.
.
MICROBIOLOGY:
[**2161-3-2**] 4:30 pm URINE Site: NOT SPECIFIED HEM# 1646E
[**3-2**].
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
.
3/6/012
[**2161-3-3**] 2:43 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2161-3-3**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2161-3-3**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Brief Hospital Course:
[**Age over 90 **]-year-old white female with a history of CAD, hyperlipidemia,
hypertension, DM, and arthritis with recent PPM placement at
[**Hospital1 **] on [**2-18**] for complete heart block (?paroxysmal av block)
and syncope who presented to [**Hospital6 33**] with altered
mental status and a displaced RV pacerlead with bradycardia now
s/p pacer lead revision.
.
# COMPLETE HEART BLOCK/RV LEAD DISPLACEMENT: The patient had a
DDD pacemaker placed at [**Hospital1 **] on approximately [**2161-2-22**] for
symptomatic (syncope) bradycardia. She was transferred to [**Hospital1 18**]
today after being found unresponsive; it was found that her RV
pacer lead had perforated her RV apex. A temporary pacing wire
was placed [**2161-3-2**] at [**Hospital3 **] without complication and she
was transferred to [**Hospital1 18**]. An echo here demonstrated no
pericardial effusion, but showed clear perforation of the RV
lead. She underwent RV lead revision, with post-operative echo
showing no complication. Repeat Echo demonstrates only minimal
pericardial fluid, but no evidence of tamponade. Patient was
monitored on telemetry and with serial EKG without additional
complication. She received a one time dose of vancomycin, and
then on discharge, will continue keflex, renally dosed, for a
total of 7 day of Abx coverage for lead revision. She will have
follow-up at device clinic on Tuesday, [**2161-3-10**].
.
# CHF: diastolic dysfunction. Patient was continued on her home
BB, ASA.
.
# [**Last Name (un) **]: Pt's Cr baseline appears to be near 1.2 as per discharge
from [**Hospital1 **] on [**2161-2-22**]. Cr was 1.7 on admission. DDx included
prerenal vs intrinsic. Cr remained stable during admission, and
on discharge was 1.6.
.
# COPD - known history of COPD. She was continued on albuterol
and ipratropium, and discharged on her home fluticasone and
salmeterol.
.
# E. Coli UTI - UA suggestive of urinary tract infection.
Culture grew > 100k E.coli with sensitivities pending. She
received a dose of ceftriaxone, and then was changed to
ciprofloxacin x 5 days on discharge. She remained afebrile, with
resolving wbc. She denied urinary symptoms while here. If
sensitivities are cephalosporin positive, ciprofloxacin could be
discontinued, as she is on keflex x 5 days for lead revision.
.
# Diarrhea: resolved. Cdiff was checked and negative.
.
# Code: DNR/DNI, confirmed with HCP
.
# Transitions:
- E.coli sensitivities from urine culture pending
- spoke with PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 15532**] at [**Hospital1 **] and updated on patient's
admission.
Medications on Admission:
HOME MEDICATIONS: From D/C summary from [**Hospital1 **] on [**2161-2-22**];
unable to confirm as pt intubated and sedated
Lactobacillus 1 tab [**Hospital1 **]
Metoprolol Tartrate 25 mg [**Hospital1 **]
Aspirin 325 mg DAILY
Enoxaparin Sodium 30 mg DAILY
Fluticasone [**Hospital1 **]
Salmeterol INH
Acetaminophen 650mg Q4H PRN
Oxycodone 1 tab Q4H PRN
Magnesium Hydroxide
Nitroglycerin 0.4 mg Q5M PRN
Discharge Medications:
1. lactobacillus acidophilus Tablet, Chewable Sig: One (1)
Tablet, Chewable PO twice a day.
2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) syringe
Subcutaneous once a day.
5. fluticasone 110 mcg/actuation Aerosol Sig: One (1) puff
Inhalation twice a day.
6. salmeterol 50 mcg/dose Disk with Device Sig: One (1) puff
Inhalation once a day.
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
9. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as
needed for constipation.
10. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 5 days.
11. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual prn as needed for chest pain: Can take 3 in 15
minutes.
12. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day for 5 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4470**] HealthCare Center at [**Location (un) 38**]
Discharge Diagnosis:
Primary:
1. Right ventricular lead revision
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
.
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted for malfunction and displacement of your pacer lead.
This was fixed with good results. You had an echocardiogram
which showed no complication.
.
You were noted to have a urinary tract infection. You will take
antibiotics for this, and also for the pacer lead revision.
.
MEDICATION CHANGES:
- START keflex 500 mg every 8 hours for 5 more days
.
Please seek medical attention for any concerns. Please attend
your follow-up appointments below.
Followup Instructions:
Department: CARDIAC SERVICES
When: TUESDAY [**2161-3-10**] at 10:00 AM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) 163**] MD [**MD Number(2) 11313**]
Completed by:[**2161-3-4**]
|
[
"53081",
"4280",
"5849",
"5990",
"41401",
"2724",
"4019",
"25000"
] |
Admission Date: [**2116-5-31**] Discharge Date: [**2116-6-12**]
Date of Birth: [**2075-3-13**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
N/V/D
Major Surgical or Invasive Procedure:
Mechanical Intubation
Central Venous Catheter Insertion (Right Internal Jugular)
Arterial Line Placement (Left Radial Artery)
PICC line placement (peripherally inserted central catheter)
History of Present Illness:
41 y/o female with PMHx congenital hepatic fibrosis, polycystic
kidney disease who presented to an OSH with profuse diarrhea
starting this morning. She notes feeling "under the weather"
for the past couple days as well. She was tachycardic to 140
with lactate of 4.5 at OSH initially. Received 6L IVF with
improvement in tachycardia to 125 with N/V/D. Vomiting bilious
emesis without blood. Diarrhea similar without evidence of
gross bleeding. Labs were notable for a WBC of 3.3 with 13%
bandemia, HCT of 35, plateltets of 38k. Patient was acidotic
with CO2 of 13 and an AG of 14. Lactate noted to be 4.0.
Patient was in [**Last Name (un) **] with creatinine of 2.8. At the OSH ED she
was given vanco/zosyn as well as 4 L NS and PO APAP. EKG showed
sinus tachycardia with minimal ST depressions in V4-V6 and a
troponin of 0.03. Given concern for severe sepsis, she was
transferred to [**Hospital1 18**] for further management.
.
In the ED, initial VS were HR 120, RR 30, BP 104/79, satting
100% on RA. T was 101.2. Labs showed leukopenia with WBC of
1.4 (baseline [**5-8**]) with 66% neuts, 20% bands, 3% atyps, anemia
to 30.1 (baseline 34), and platelets to 27 (baseline 100), Ca of
6.1, Mg of 1.0, K of 2.8, bicarb of 13, Cr of 2.4. Coags showed
PT: 27.3, PTT: 43.7, INR of 2.6. Lactate was 2.5. She was
given 2 amps Calcium gluconate, 2gm mag sulfate, ipratropium,
and flagyl 500mg IV. She had a CT A/P that showed her right
colon is completely collapsed which could be c/w colitis, but no
clear infectious etiology.
.
On arrival to the MICU, patient is alert but in moderate
respiratory distress speaking in broken sentences.
Past Medical History:
congenital hepatic fibrosis
polycystic kidney disease
portal hypertension with splenomegaly
one cord of grade [**2-3**] varices in the lower third of the
esophagus
Gastric varices
Old portal vein thrombosis
history of DVTs in the setting of taking oral contraceptives
history of cholecystectomy
asthma
history of back surgery with S1 procedure with noted chronic
back pain.
Failed pregnancy requiring a D&C.
s/p tubal ligation
Chronic kidney disease (baseline Cr 1.6-1.7)
Social History:
Works as bank teller. Lives alone. No new sexual contacts. [**Name (NI) **]
IVDU
Family History:
Brother with reported history of clotting disease with unknown
cause
Mother is noted to have died at age 52 from uterine cancer and
also had clotting disorder(unknown type).
Mother's mother with history of colon cancer, died at age 62
Physical Exam:
ADMISSION PHYSICAL EXAM
General: Alert, oriented, moderate respiratory distress/fatigued
HEENT: Pale. Sclera anicteric, Dry MM, oropharynx with thick
mucous, no oral petechiae, EOMI, PERRL
Neck: supple, JVP flat, no LAD
CV: Tachycardic, otherwise normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds, right worse than left. RLL with
very depressed breath sounds. No crackles or wheezes.
Abdomen: NBS. soft, but TTP in the epigastric region without
rebound. No organomegaly appreciated.
GU: clear urine
Ext: warm, bounding pulese.
Neuro: CNII-XII intact, 4/5 strength upper/lower extremities,
grossly normal sensation, MAE
Skin: No evidence of petechiae on upper/lower extremities or on
back. Abdomen with ? cherry angiomas.
Discharge PE:
VS: Tm 99.8 Tc 98.6 126/78 (126-148/73-84) 87 (81-116) 20 100RA
UO: -1050 8h/ -[**2054**] 24h
2 BMs overnight, 8 BMs in last 24h
General: middle aged woman, well appearing, well nourished,
sleeping comfortably in bed, NAD
HEENT: EOMI, PERRL
CV: RRR, S1 S2, no murmurs/rubs/gallops
lungs: CTA b/l, no wheezes/rhonchi/crackles appreciated
abdomen: soft, nontender, nondistended, +BS, no hepatomegaly
appreciated
extremities: trace LE edema b/l, warm, well perfused, 2+ DP
pulses
R arm with PICC: 2+ radial pulses, no increased swelling noted
Neuro: normal muscle strength and sensation throughout, CN 2-12
grossly intact
Pertinent Results:
Admission Labs:
[**2116-5-31**] 04:30PM BLOOD WBC-1.4*# RBC-3.19* Hgb-9.9* Hct-30.1*
MCV-94 MCH-31.2 MCHC-33.0 RDW-13.3 Plt Ct-27*#
[**2116-5-31**] 04:30PM BLOOD Neuts-66 Bands-20* Lymphs-10* Monos-1*
Eos-0 Baso-0 Atyps-3* Metas-0 Myelos-0
[**2116-5-31**] 04:30PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-2+
[**2116-5-31**] 04:30PM BLOOD PT-27.3* PTT-43.7* INR(PT)-2.6*
[**2116-5-31**] 04:30PM BLOOD FDP-10-40*
[**2116-6-1**] 05:00PM BLOOD Parst S-NEGATIVE
[**2116-5-31**] 04:30PM BLOOD Glucose-94 UreaN-32* Creat-2.4* Na-141
K-2.8* Cl-113* HCO3-13* AnGap-18
[**2116-5-31**] 04:30PM BLOOD ALT-23 AST-35 LD(LDH)-188 AlkPhos-20*
TotBili-1.4
[**2116-6-1**] 01:19AM BLOOD CK-MB-2 cTropnT-<0.01
[**2116-5-31**] 04:30PM BLOOD Albumin-2.6* Calcium-6.1* Phos-3.5
Mg-1.0*
[**2116-5-31**] 04:30PM BLOOD Hapto-40
[**2116-6-2**] 09:37AM BLOOD Cortsol-88.2*
[**2116-6-1**] 05:04AM BLOOD HIV Ab-NEGATIVE
[**2116-6-1**] 11:47PM BLOOD Vanco-14.9
[**2116-5-31**] 06:32PM BLOOD Type-ART pO2-88 pCO2-26* pH-7.30*
calTCO2-13* Base XS--11 Intubat-NOT INTUBA
[**2116-5-31**] 04:30PM BLOOD Lactate-2.5*
[**2116-6-1**] 10:33AM BLOOD Lactate-6.3*
[**2116-6-1**] 01:32AM BLOOD freeCa-1.03*
IMAGING
Portable CXR
FINDINGS: As compared to the previous radiograph, the patient
has received a right internal jugular vein catheter. The tip of
the catheter projects over the right atrium and should be pulled
back by approximately 5-6 cm to ensure correct position in the
superior vena cava. IV team was paged at the time of observation
and dictation, 8:09 a.m., [**2116-6-1**].
There is no evidence of complications, notably no pneumothorax.
Unchanged retrocardiac atelectasis and moderate cardiomegaly, no
evidence of pneumonia.
Discharge labs:
[**2116-6-12**] 06:29AM BLOOD WBC-4.9 RBC-2.55* Hgb-7.9* Hct-23.7*
MCV-93 MCH-30.8 MCHC-33.1 RDW-13.7 Plt Ct-92*
[**2116-6-12**] 06:29AM BLOOD Glucose-90 UreaN-20 Creat-1.3* Na-139
K-4.0 Cl-112* HCO3-21* AnGap-10
[**2116-6-12**] 06:29AM BLOOD Calcium-7.8* Phos-4.0 Mg-1.9
Micro:
[**2116-5-31**] 4:30 pm BLOOD CULTURE
**FINAL REPORT [**2116-6-6**]**
Blood Culture, Routine (Final [**2116-6-6**]):
KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final [**2116-6-1**]):
GRAM NEGATIVE ROD(S).
Reported to and read back by [**Last Name (LF) **],[**First Name3 (LF) **] -CC7D- @ 10:45
[**2116-6-1**].
Brief Hospital Course:
Ms. [**Known lastname 32357**] is 41F with a h/o PCKD, congenital hepatic fibrosis
with portal hypertension and esophageal varices, h/o DVTs, s/p
cholecystectomy, admitted with septic shock, klebsiella
bacteremia, and respiratory failure following a prodrome of
n/v/diarrhea.
# Septic Shock [**3-5**] Klebsiella bacteremia: Presented from OSH
initially with nausea/vomiting/diarrhea and fevers. Transferred
with profound sepsis and evidence of shock with end organ
ischemia including elevated lactate and renal failure. On
arrival to [**Hospital1 18**], right internal jugular vein line was
emergently placed, and patient was intubated for respiratory
failure given overhwhelming metabolic acidosis and inability to
maintain respiratory compensation. Left radial arterial line
was placed as patient was necessitating support with
norepinepherine and vasopressin. Initially continued on broad
spectrum antibiotics with Vancomycin and
Piperacillin/Tazobactam. Continued to spike and ID consult was
performed. Antimicrobial coverage was initially broadened with
doxycylcine as well as IV metronidazole, PO Vancomycin as
patient was having large volume diarrhea and empiric therapy for
C.Difficile and potential zoonoses. As she continued to spike
fevers, GNR's were growing in her blood stream and
Piperacillin/Tazobactam was switched with meropenem to
empirically cover ESBL GNR's.
Outside hospital cultures were growing Klebsiella Pneumoniae
resistant to piperacillin/tazobactam. Lactate levels continued
to increase, at one point >6, with no hemodynamic improvement.
Surgery was consulted at that time for potential exploratory
laporatomy given concern for diffuse bowel necrosis. However,
prior to surgery, patient sufferred a STEMI, and the decision
was made to hold off on exploratory laporatomy. As no other
source of infection was identified and organ perfusion began to
improve with aggressive hydration, her antimicrobial therapy was
weaned to just meropenem, then switched to ceftriaxone once in
house sensitivities came back. No source was identified,
although abdominal CT scan showed possible right sided colitis.
As no source was revealed, a tagged WBC scan was pursued which
was negative. Lactate continued to downtrend and renal function
improved over the next several days. Patient was extubated and
off pressors by HD 10. The patient also had a WBC scan which
was negative.
On transfer to the general medicine floor, the patient was
continued on IV Ceftriaxone, with end date [**2116-6-19**].
# Hypercarbic Respiratory Failure: Intubated on HD#1 given
overwhelming acidosis and inability to maintain respiratory
compensation. She was extubated on [**2116-6-7**] without issue.
Barriers to extubation were volume overloaded status, as she was
aggressively volume resuscitated in the setting of severe
sepsis.
# STEMI: On admission, patient fell into multiple bouts of SVT
to 180's which broke with adenosine. She was briefly placed on
a diltiazem gtt for rate control while on pressors. On HD#2,
patient sufferred a STEMI with evidence of cardiac biomarker
elevation consistent with an inferior lateral myocardial
infarction. Empiric heparin was started for 48 hours then
discontinued. Cardiology was following and it was decided that
she was too sick for catheterization at this time. TTE was
performed which confirmed this, with a new EF of 40%. As her
platelets continued to increase, a baby aspirin was initiated.
As she became more hemodynamically stable, beta blockers were
initiated as well as a statin. As her renal function continued
to change, an ACE-I was not initiated.
Upon discharge, the patient was initiated on lisinopril and
continued on her atorvastatin, metoprolol, and aspirin. As per
cards, there is no need for urgent cath at this time and she
should follow up with an outpatient stress test.
#[**Last Name (un) **]/CKD: baseline creatinine 1.6-1.7, underlying PCKD. Acute
kidney injury likely a result of pre renal failure progressiving
to acute tubular necrosis from hypotension. Renal initially
consulted for potential dialysis, although was not necessary to
puruse. As sepsis resolved with hemodynamic improvement,
creatinine continued to improve to baseline values.
While on the floor, the patient was auto-diuresing well, with
creat trending down to 1.2. Because of this improvement in her
creat, lisinopril was restarted upon discharge.
#Anemia/Thrombocytopenia: Has baseline thrombocytopenia of about
[**Numeric Identifier **] platelets. Initially profoundly thrombocytopenic with
accompanying anemia initially concerning for DIC.
Hematology/Oncology was consulted in the emergency room, and
voiced no schistocytes evidence on peripheral smears. As sepsis
involved, platelets continued to improve. Her anemia remained
stable, but she was given blood transfusions in the setting of
HCT< 27 and new STEMI.
While on the floor, the patient's crit and platelets were
trended.
#Hypernatremia: After massive fluid resuscitation, started to
have evidence of hypernatremia around HD6/7. Fluid water
deficit was calculated to >4.5 liters. Free water boluses were
started with her tube feeds, and IV D5W was started with sodium
monitoring. No evidence of diabetes insipidus was seen on urine
studies. Sodium corrected to 140 by HD #11, and while on the
general medicine floor, her sodium was trended.
#Left arterial thrombus: Arterial line was placed per above for
hemodynamic monitoring. Evidence of flattened a-line with blood
clot seen on ultrasound. Vascular surgery was consulted given
thrombus and also evidence of distal ischemia on fingers/toes in
the presence of pressor use. Vascular suggested topical
nitropaste for improved perfusion, and empiric heparin gtt would
also adequately treat thrombus along with STEMI per above.
Perfusion improved with nitropaste, and heparin gtt was
discontinued given thrombocytopenia.
#Right Upper Extremity Superficial Thrombus: RUE found to have
non-occlusive basillic and occlusive cephalic vein thrombus,
after developing R arm swelling the setting of placing right
PICC line. This edema resolved the following day. As per the
PICC team, ok to continue using the PICC as long as the patient
does not develop any new R arm swelling, tenderness, or pain.
She will be discharged with PICC to complete treatment with
ceftriaxone. At the time of discharge both of her arms were
equal in size.
Transitional Issues:
- The patient will need to continue Ceftriaxone, end date
[**2116-6-19**]. She will need the PICC line removed once antibiotic
course is completed. Please check LFT's on [**2116-6-17**].
- The patient is s/p STEMI while in the MICU. She will need an
outpatient stress test. Her metoprolol and lisinopril need to be
titrated up as necessary.
- The patient was just started on Lisinopril; it was initially
being held due to [**Last Name (un) **]. Please check her creatinine and lytes on
[**2116-6-17**].
- The patient is anemic and thrombocytopenic related to her
recent sepsis. Please check her CBC on [**2116-6-17**].
Medications on Admission:
bupropion 150mg
lansoprazole 15mg
sertraline 50mg
Discharge Medications:
1. ceftriaxone 2 gram Piggyback Sig: One (1) Intravenous once a
day: STOP [**2116-6-19**].
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO once a day.
5. lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO once a day.
6. sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day.
7. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
Three (3) Tablet Extended Release 24 hr PO once a day.
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
primary diagnosis:
Klebsiella sepsis
ST elevation myocardial infarction
colitis
Acute on Chronic Renal Failure
Thrombocytopenia
Arterial Thrombus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Needs assistance.
Discharge Instructions:
Dear Ms. [**Known lastname 32357**],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were transferred to [**Hospital1 18**] because you were very
ill and found to have a bacterial infection in your blood. While
you were in the intensive care unit you were intubated (had a
tube down your throat helping breathe for you) and needed
medications to maintain your blood pressures. We gave you
antibiotics which treated the infection and you were ultimately
able to breathe on your own and maintain your own blood
pressures.
While you were in the intensive care unit, you sufferred a heart
attack. The cardiologists were contact[**Name (NI) **] and it was decided to
not go ahead and do any procedures at that time because you were
so sick. However, we did start you on medications that will help
optimize your heart function. You will need to have a stress
test performed as an outpatient to help decide if you need
further procedures.
We made the following changes to your medications:
START Ceftriaxone 2 grams daily through your veins (END DATE
[**2116-6-19**])
START metoprolol 75 mg by mouth daily
START atorvastatin 80 mg daily
START aspirin 81 mg daily
START lisinopril 5 mg daily
Followup Instructions:
Name:[**Name6 (MD) 32358**] [**Name8 (MD) **],MD
Specialty: Priamry Care
Location: [**Hospital1 **] FAMILY PRACTICE
Address: 1020 [**Location (un) **], [**Hospital1 **],[**Numeric Identifier 23011**]
Phone: [**Telephone/Fax (1) 32359**]
Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Department: CARDIAC SERVICES
When: THURSDAY [**2116-6-25**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2116-6-13**]
|
[
"78552",
"51881",
"5845",
"2762",
"2760",
"99592",
"49390",
"53081",
"4168",
"3051"
] |
Admission Date: [**2151-11-18**] Discharge Date: [**2151-11-24**]
Date of Birth: [**2080-11-30**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt. is a 70 yo female with PMH of stage IV sarcoidosis,
resulting COPD with obstructive and restrictive components, and
diastolic CHF who presents with worsening SOB and tacchypnea
with resp rates in the 30s. Patient was on steroid taper
starting [**10-21**] and tapered off last thursday. On monday, she
reports feeling more sob with productive cough of clear sputum
and non-bloody. Denies fever or chills. Feels very wheezy. No
travel or sick contacts. [**Name (NI) **] flare before this one was last
year in [**Month (only) **]. She denies URI symptoms, chest pain, nausea,
vomiting. She has had decreased appetite recently. Her initial
vs in the ED were: T 99.3 P 110 BP 160/70 R 35 100 %O2 sat.
.
In the ED, she got 2 hrs continuous albuterol and ipratropium
bromide nebs as well as 1g of ceftriaxone, 500mg of
azithromycin, 125 mg IV solumedrol, and 2 g Mag. She had
increasingly acidotic blood gases with pH to 7.19 with pCO2 to
91. She refused intubation. She was started on bipap 35% FIO2,
ps 15 peep 5 in the ED prior to transfer and ABG improved to
7.33/63/97/35.
.
On admission to the [**Hospital Unit Name 153**], patient's vs were: T 96.5 P 93 BP
128/49 R 21 O2 sat 93% on bipap. She appeared tacchypneic but
was able to speak in complete sentences. Pt reports that she
felt much better than when she came to the ED.
Past Medical History:
- sarcoidosis, stage IV, chronic and fibrotic. No h/o
ophthalmic, hepatic, dermatologic or renal manifestations
- COPD with combined obstructive/restrictive lung disease
- on home O2
- HTN
- Pulmonary hypertension
- diastolic CHF
- Anemia
Social History:
Lives with husband, has three children, retired medical
assitant. Denies etoh, tob, drug. Upon questioning she states
that she was exposed to tuberculosis as a child (she thinks
around age 12) because her uncle and aunt had it. During her
adult life, she states that she was checked yearly with the
tuburculin skin test which was negative. At one time it was
positive, and she had to leave work for a couple of weeks to get
it checked out, but said that "it was wrong. With the other
tests they knew I didn't have TB". She had subsequent TB tests
that were negative, last one years ago.
Family History:
Cousin with sarcoidosis, no CV disease in family.
Physical Exam:
Admission:
vitals: T 96.5 BP 128/49 HR 93 RR 21 SpO2 98% on bipap 15/5
general: tacchypneic, able to speak in complete sentences
heent: NCAT, anicteric, no injectins, PERRLA, MM dry
pulm: prolonged I: E ratio, tight wheezing insp and exp but
moving air throughout, no crackles
cv: tacchy, reg rhythm, no mgr
abd: +bs, soft, nt, nd, no masses or hsm
extr: no cce, pedal pulses 2+ b/l
neuro: A/O x 3
Pertinent Results:
CHEST (PORTABLE AP) Study Date of [**2151-11-18**] 4:33 PM
UPRIGHT CHEST: Compared to [**2150-12-18**] there has been little
change. Extensive fibrotic changes in the upper lobes
bilaterally and elevated hilar structures. Multiple calcified
lymph nodes are unchanged and consistent with changes related to
sarcoid. Increased lucency of the more inferior pulmonary
tissues demonstrates no new opacities or infiltrates. Position
of diaphragms again may represent underlying COPD. Calcified
bilateral breast implants appear unchanged as does a _____ right
hemiarthroplasty of the shoulder.
IMPRESSION: Chronic changes related to sarcoid and underlying
COPD. No acute cardiopulmonary process.
Brief Hospital Course:
70 yo with severely obstructive COPD from sarcoidosis presents
with SOB and hypercapneic respiratory failure. On admission, she
was diagnosed with a COPD exacerbation. Given a relatively
normal BNP, EF> 75% and dry status on physical exam, her lasix
was held; her lasix QOD was eventually restarted after she
became euvolemic. She was started on Solumedrol 125mg IV q6hrs,
Azithromycin and Ceftriaxone for COPD with moderate amount of
yellow/green sputum production. In addition, she was given
Ipratropium and Albuterol nebs - initially on continuous
Albuterol. She was also started on BiPap for increased
respiratory effort, tachypnea and ABG showing severe respiratory
acidosis with pH7.21 and pCO2 91. She tolerated BiPap well and
was maintained on it for the next two days with intermittent
breaks on nasal canula. Her breathing became less labored and
serial ABG's showed decreasing hypercapnia. On HD 3, she was
transitioned to nasal cannula and was able to maintain oxygen
saturations. In addition, her steroid dose was decreased to
Prednisone 60mg daily. Placing the patient on PCP prophylaxis
given her chronic steroid use was discussed but deferred in the
ICU setting.
She was transferred to the medical floor where she continued to
be stable on 2 L pm Nasal cannula, combivent nebs prn (approx q
4 hours), and 60 mg of prednisone.
Her antibiotics were transitioned to oral cefpodoxime and
azithromycin was discontinued.
She was discharged home with services and a long steroid taper
(down by 10 mg every five days)
Medications on Admission:
Albuterol nebs
Atrovent, 2 puffs, 4 x daily
Verapamil, 240 mg daily
calcium twice daily
Singulair, 10 mg nightly
Lasix, 20 mg QOD
supplemental oxygen 2 l nc
iron 325 qd
p.r.n. insulin
last flu shot was one day prior to admission
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*0*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*180 neb* Refills:*0*
5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*180 neb* Refills:*0*
6. Cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
7. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*0*
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) blister inhalation Inhalation twice a day.
Disp:*1 disc and device* Refills:*0*
10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
11. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
12. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO TIW.
Disp:*12 Tablet(s)* Refills:*0*
13. Insulin Regular Human 100 unit/mL Solution Sig: as directed
by sliding scale (included) Units, insulin Injection ASDIR (AS
DIRECTED): as directed by sliding scale (included).
14. Prednisone 10 mg Tablet Sig: as directed below Tablet PO
once a day for 35 days: Starting on [**2151-11-25**]
6O mg for five days
50 mg for five days
40 mg for five days
30 mg for five days
20 mg for five days
10 mg for ten days
then stop.
Disp:*110 Tablet(s)* Refills:*0*
15. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
COPD exacerbation
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Return to the [**Hospital1 18**] Emergency Department for:
Shortness of breath
Fevers
Followup Instructions:
Call your primary doctor for a follow up appointment for within
two weeks of leaving the hospital: [**Last Name (LF) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 3511**]
Call Dr. [**Last Name (STitle) **] for a follow up appointment for within one
month of leaving the hospital: ([**Telephone/Fax (1) 513**]
|
[
"51881",
"4280",
"2762",
"4019",
"4168"
] |
Admission Date: [**2142-7-17**] Discharge Date: [**2142-7-18**]
Date of Birth: [**2080-3-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
fatigue, increased leg edema, dyspnea on exertion, recurrent
atrial fibrillation/flutter
Major Surgical or Invasive Procedure:
Atrial Tachycardia Ablation
History of Present Illness:
62 year old patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 65453**] and Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] with recurrent atrial fibrillation, who underwent left
atrial tachycardia ablation, now transferred to the CCU for
closer monitoring.
.
This 62 year old gentleman has a long history of atrial
fibrillation/atrial flutter dating back to [**2130**]. He has had
multiple cardioversions over the year and ultimately had an
atrial flutter ablation in [**2132**]. He developed recurrent atrial
fibrillation in [**2133**]-[**2134**] and had an atrial fibrillation
ablation that was complicated by a pericardial effusion in [**2136**].
He developed recurrent atrial fibrillation about 6 months later.
He reports that had another type of atrial ablation in [**2138**]. He
had been doing well from [**2138**] to [**2142-4-6**]. He had suffered a
fall with an injury to his ankle. He also had a lapse in his
Flecainide for approximately 10 days. He underwent cardioversion
in [**2142-5-7**] on [**Hospital3 **] and then went back into afib/flutter
again 4-5 days later and had another cardioversion in early [**Month (only) 205**]
[**2141**]. He remained in sinus rhythm for about 2 days when he
reverted again back to atrial fibrillation accompanied by severe
shortness of breath. He was started on Diltiazem in addition to
his Flecainide and Amiodarone and reports that he has
spontaneously converted back to ? atrial tachycardia, according
to the patient.
.
Admitted for ablation yesterday. Was cardioverted into
junctional rhythm after procedure then sent to PACU- remained
intubated. Extubated around midnight and observed before being
sent to the CCU. Sheath removed at 2045.
.
On arrival to the CCU, vitals are T 99.1, HR 80, BP 125/75, RR
18, Sa02- 95% on CPAP. Patient doing well. Stable. No
clinical complaints.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis. He
denies recent fevers, chills or rigors. He denies exertional
buttock or calf pain. All of the other review of systems were
negative.
.
While in atrial fibrillation, he experiences fatigue, increased
leg edema and dyspnea on exertion.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
Hypertensive heart disease
Asthma
Hyperlipidemia
Atrial fibrillation/atrial flutter s/p atrial fibrillation
ablation
Obstructive sleep apnea, uses CPAP (requested to bring with pt)
cardiomyopathy
Hypothyroidism
Social History:
Lives with: Married and has an 18 year old son and 14 year old
daughter.
Occupation: Owns a broadcasting company for radio stations on
[**Hospital3 **]
ETOH: No
Tobacco: No
Contact person upon discharge: Wife: [**Telephone/Fax (1) 83360**].
Home Services: No
Family History:
father died of [**2142-2-4**] at age 88 . Had CABG in his 70s.
Mother has afib. 2 brother have afib, 1 has had ablation. 3
sisters are healthy.
.
(-) TIA (-) CVA (-) Melena/GIB
Physical Exam:
VS: T 99.1, HR 80, BP 125/75, RR 18, Sa02- 95% on CPAP
GENERAL: Awake, alert. NAD. Oriented, pleasant.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: No LAD. Supple. JVP unable to be assessed.
CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Obese. Soft, NTND. No HSM or tenderness. No abdominial
bruits.
EXTREMITIES: Trace-1+ pitting edema b/l. No cyanosis or
clubbing. No femoral bruits. No hematoma, ecchymosis or signs
of infection at sheath site.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Radial 2+ DP dopplerable PT dopplerable
Left: Radial 2+ DP 2+ PT dopplerable
Pertinent Results:
No studies/additional imaging on this admission.
.
On admission:
WBC 7.6, Hb 13.1, Hct 41.1, plt 303
Na 139, K 4.0, Cl 106, bicarb 25, BUN 17, Cr 1.1, glu 117
.
On discharge:
WBC 11, Hb 12.4, Hct 38.8, plt 281
Na 143, K 4.0, Cl 106, bicarb 26, BUN 16, Cr 1.2, glu 108
Brief Hospital Course:
62 y/o male with long-standing history of refractory and
recurrent A-fib/flutter despite multiple ablations and
antiarrhythmic treatments admitted to the CCU s/p repeat atrial
ablation.
.
# RHYTHM: s/p left sided AT ablation [**2142-7-17**]. Had to be
cardioverted post ablation into junctional rhythm. Held all
nodal blocking agents for 12 hours, and patient remained in NSR.
Prior to discharge, pt had been in NSR x 24 hours, and was
restarted on his home amiodarone and flecainide. His diltiazem
was discontinued, as it was originally started for rate control,
and he does not require rate control currently. Pt was
re-started on his home coumadin regimen. INR 2.7 on discharge.
.
# Visual disturbance - pt mentioned mild visual disturbance,
left eye, felt to be related to retinal artery floaters,
post-procedure. Visual field testing performed without deficits
and neurologic exam without abnormalities. Patient instructed
to see opthalmology if persistent, although symptoms are
expected to resolve within 24-48 hours.
.
# CORONARIES: pt was continued on his home aspirin and zocor.
He was discharged on this regimen.
.
# PUMP: EF of 40-45%. No signs of overt fluid retention on
exam, with trace BLE edema. Pt was given lasix 20 mg IV prior
to discharge.
.
# OSA - CPAP per home settings were continued. Per respiratory
therapy, pt was requiring increased CPAP settings to maintain
oxygenation. Given his 60-80 lb weight gain, and the fact that
his last sleep study was 8+ years ago, pt was referred for
another sleep study at [**Hospital1 18**].
.
# Hyperlipidemia - low fat, low cholesterol diet was continued.
Zocor per home regimen was continued.
.
# HTN - stable, continued on low Na diet.
.
# Hypothyroidism - stable, was continued on home Lexothyroxine
75mcg daily.
.
# Anticoagulation - INR 2.7 on discharge. Goal INR [**1-9**].
Patient will resume home regimen of coumadin on discharge.
.
# Dispo: discharge to home
Medications on Admission:
Amiodarone 100mg daily ([**12-8**] of 200mg)
Flecainide 150mg [**Hospital1 **]
Cardizem 60mg 1 tablet 3 times daily
Levothyroxine 75mcg daily
Warfarin 5mg/7.5mg alternating doses, instructed to take 5mg MON
night per Dr. [**Last Name (STitle) **] for INR of 2.9 on Monday
Zocor 20mg daily
Aspirin 325mg daily
Vitamin C 2000mg daily
Vitamin D3 2000mg [**Hospital1 **]
Vitamin E 4000 IU daily
Salmon oil 1000 daily
DHA daily
Cod liver oil daily
Carnatine daily
L- carnatine
Tumeric daily
Cursamin daily
Alphalipoic acid 600mg daily
Calcium-magnesium-potassium [**Hospital1 **]
Magnesium 400mg [**Hospital1 **]
Arginine daily
Boron daily
Chromium
Albuterol PRN for SOB
Discharge Medications:
1. Amiodarone 100 mg Tablet Sig: One (1) Tablet PO once a day.
2. Flecainide 150 mg Tablet Sig: One (1) Tablet PO twice a day.
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO once a
day.
4. Warfarin 5 mg Tablet Sig: 1 - 1 [**12-8**] Tablet PO once a day: Per
INR.
5. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
7. Vitamin C 1,000 mg Tablet Sig: Two (2) Tablet PO once a day.
8. Vitamin D-3 2,000 unit Tablet Sig: Two (2) Tablet PO once a
day.
9. Vitamin E Oral
10. Salmon Oil-1000 1,000-200 mg Capsule Sig: One (1) Capsule PO
once a day.
11. DHA-EPA-Policos-B6-B12-FA-Phyt Oral
12. Cod Liver Oil Capsule Sig: One (1) Capsule PO once a
day.
13. carnatine Sig: One (1) once a day.
14. l-carnatine Sig: One (1) once a day.
15. tumeric Sig: One (1) once a day.
16. cursamin Sig: One (1) once a day.
17. Alpha Lipoic Acid 300 mg Capsule Sig: Two (2) Capsule PO
once a day.
18. calcium magnesium potassium Sig: One (1) twice a day.
19. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a
day.
20. Arginine (L-Arginine) Oral
21. boron Sig: One (1) once a day.
22. Chromium Oral
23. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puffs Inhalation q 4-6 hours as needed for shortness of
breath or wheezing.
24. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: For 4 weeks.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
25. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
26. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO three times
a day as needed for chest pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Atrial Tachycardia Ablations
Atrial Fibrillation/Atrial Tachycardia
Hypertension
Hyperlipidemia
Asthma
OSA
Hypothyroidism
Discharge Condition:
v/s: afeb, 91% on RA, HR 82, BP
Lungs: CTAB
CV: RRR
Ext: mile peripheral chronic edema
Discharge Instructions:
You had an atrial tachycardia ablation for recurrent atrial
arrhythmias. There were no complications. You were in the CCU
overnight so we could monitor your breathing. You are now in
normal sinus rhythm. You had some visual changes that may be
from a tiny blood clot in the vessels near your eye. This should
resolve on its own. Please make an appt to see your
opthamologist to get a thorough eye exam. The opthamologist will
tell you if your vision is adequate for driving.
Please take all medications as prescribed. No pools or baths for
one week. You may shower and cover the groin access sites with a
band-aid. No driving for 48 hours.
.
Medication changes:
1. You will be started on omeprazole 40 mg daily for 4 weeks.
2. Start a baby aspirin 81 mg daily
3. STOP taking Cardizem
If you have chest pain, shortness of breath, pain/swelling at
groin sites, fever - please call Dr. [**First Name (STitle) 65453**]
Followup Instructions:
Cardiology electrophysiology:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 33732**] Date/time: [**8-10**] at
1:00pm.
.
Primary Care:
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 65453**] Phone: [**Telephone/Fax (1) 77632**] Date/time: Please keep
your previously scheduled appt on [**8-2**]
Completed by:[**2142-7-18**]
|
[
"42789",
"42731",
"2449",
"2720",
"32723"
] |
Admission Date: [**2171-6-25**] Discharge Date: [**2171-7-24**]
Date of Birth: [**2108-11-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
R IJ central line
PICC line placed for long term IV access for intravenous
antibiotics.
Cholecystostomy tube placed by radiology
Foley catheter
History of Present Illness:
Mr. [**Known lastname 99500**] is a 62 year old gentleman with history of multiple
sclerosis, [**Known lastname 862**] disorder, dementia, and chronic indwelling
foley with recurrent UTIs (including ESBL klebsiella) presented
from his nursing home with altered mental status. In
communication with his PCP and [**Name9 (PRE) **] [**Last Name (Titles) **], the patient's
baseline mental status is alert and talkative(occasionally
rambling), but he became lethargic and somnolent beginning the
day prior to admission at the nursing home. He reportedly had a
U/A and culture sent 3 days prior to admission which revealed
VRE (reportedly only sensitive to macrodantin) and proteus. His
nurse practitioner felt he was likely colonized with VRE and
proteus was sensitive to ampicillin, thus he was started on
ampicillin at that time. At that time, he was also felt to be
fecally obstructed, so he was given a fleets enema to which he
responded well. On the evening prior to admission, in addition
to his change in mental status, he was found to be tachycardic
to the low 100s. He was, however, afebrile and systolic blood
pressures were consistently in the 100s-120s. His mental status
declined overnight at the nursing home and he was transferred to
the ED for further evaluation and management.
.
In the ED, his initial vitals revealed: HR 107 BP 98/28 RR 14
O2sat 100%on NRB-->RA; no temperature was recorded. He was
noted to have abdominal discomfort and suprapubic fullness. His
foley was found to be obstructed and when resolved, was noted to
drain frank pus from his bladder. Labs demonstrated WBC count
of 27 with 16% bandemia and an elevated lactate to 10.5 which
decreased to 8.6 with IV fluids. A CT abd/pelvis was obtained
to rule out bowel ischemia and surgery was consulted. CT
abd/pelvis did not reveal ischemia of the gut, but did note
thickening of perirectal and sigmoid wall believed consistent
with chronic laxative use vs. infectious/inflammatory etiology.
A CXR showed a retrocardiac opacity thought to represent
atelectasis vs. consolidation. Blood and urine cultures were
sent and he received vanco/levofloxacin/flagyl. Given his
altered mental status, a head CT was obtained which was negative
for hemorrhage and mass effect.
.
Although it is not clearly documented, he reportedly received 7L
NS IV fluid resuscitation. His ED course was complicated by
multiple attempts at central venous access and he was initially
started on peripheral dopamine to maintain his blood pressure.
A right IJ was then placed and MAPs remained in the low 50s so
levophed was started in addition to dopamine prior to his
transfer to the ICU.
.
ROS: Unable to obtain secondary to altered mental status.
Past Medical History:
# Secondary Progressive MS: first symptoms in [**2125**]; received
courses of steroids in the past; diagnosed at [**Hospital1 2025**]; now with
dementia, decreased vision, paraplegia and decreased function UE
L>R, unable to ambulate for the past 6 yrs; Foley;
# [**Hospital1 **] Disorder: no seizures since [**2168**], has been on PHT and
tegretol
# Frequent UTIs (Klebsiella ESBL in past)
# [**Year (4 digits) **] retention
# Trigeminal Neuralgia
# GERD
# decub ulcers back and feet
# decreased vision (20/400)
# Temporomandibular Joint pain
# Thoracic spine stage IV decubitus ulcer
Social History:
Sister very involved in care and health care proxy. [**Hospital 8304**]
Nursing home resident.
Full code.
Family History:
Non-contributory.
Physical Exam:
PE: T 97.3 HR 115 BP 106/44 RR 15 O2sat 100% NRB CVP 8-9
Gen: Pale, unresponsive to sternal rub, withdraws LUE when
attempting ABG, moving left LE spontaneously, unresponsive to
simple commands
Neck: No carotid bruits appreciated
HEENT: Dry MM, PERRL, gaze conjugate, no roving eye movements
CV: sinus tachy, no mrg appreciated
Resp: CTA anteriorly, clear posteriorly, but not moving large
amounts of air
Abd: +BS, soft, distended, no palpable masses, does not respond
to deep palpation of abdomen
Back: Stage 2 ulcer on thoracic spine, no evidence of purulence
nor surrounding cellulitis, dressed with duoderm
Ext: Toes cool b/l, but with good DP/PT pulses b/l, upper limit
normal capillary refill time
Neuro: See above.
Pertinent Results:
[**2171-6-25**]
9:43p
Source: Line-aline
141 108 31 128 AGap=21
3.3 15 1.1
Ca: 7.5 Mg: 1.7 P: 3.4
[**2171-6-25**]
8:00p
pH
7.36 pCO2
31 pO2
155 HCO3
18 BaseXS
-6
Type:Art; Not Intubated; Cool Neb; FiO2%:70; Temp:36.7
Lactate:4.7
Comments: Lactate: Verified
[**2171-6-25**]
5:07p
Source: Line-central line
SLIGHTLY HEMOLYZED
142 109 32 130 AGap=19
3.7 18 1.2
Comments: K: Hemolysis Falsely Elevates K
CK: 2496 MB: 44 MBI: 1.8 Trop-T: 0.03
Comments: CK(CPK): Verified By Dilution
cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Ca: 6.8 Mg: 1.7 P: 3.5
Comments: Mg: Hemolysis Falsely Elevates Mg
[**2171-6-25**]
5:00p
Lactate:4.9
Comments: Lactate: Verified
O2Sat: 75
[**2171-6-25**]
2:20p
ALB & CARBA ADDED [**6-25**] @ 15:49; MODERATELY HEMOLYZED SPECIMEN
ALT: AP: Tbili: Alb: 2.7
AST: LDH: Dbili: TProt:
[**Doctor First Name **]: Lip:
Carbamaz: 2.4
Other Blood Chemistry:
Cortsol: 43.7
Comments: Cortsol: Normal Diurnal Pattern: 7-10am 6.2-19.4 /
4-8pm 2.3-11.9
[**2171-6-25**]
2:16p
pH
7.27 pCO2
33 pO2
128 HCO3
16 BaseXS
-10
Type:Art; Temp:36.1
Na:140
K:3.5
Cl:115 Glu:169
Lactate:6.6
Comments: Lactate: Verified
[**2171-6-25**]
1:50p
DIL ADDED 2:32PM; SLIGHTLY HEMOLYZED SPECIMEN
Phenytoin: 9.4
Other Blood Chemistry:
Cortsol: 39.8
Comments: Cortsol: Normal Diurnal Pattern: 7-10am 6.2-19.4 /
4-8pm 2.3-11.9
[**2171-6-25**]
1:00p
Other Blood Chemistry:
Cortsol: 30.1
Comments: Cortsol: Normal Diurnal Pattern: 7-10am 6.2-19.4 /
4-8pm 2.3-11.9
Other Urine Chemistry:
UreaN:246
Creat:17
Na:93
Osmolal:308
Other Hematology
FDP: 160-320
PT: 17.9 PTT: 35.5 INR: 1.7
Fibrinogen: 486 D
Other Hematology
D-Dimer: 6786
[**2171-6-25**]
10:22a
Lactate:5.9
Comments: Lactate: Verified
[**2171-6-25**]
10:20a
Trop-T: 0.02
Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
142 109 41 160 AGap=23
3.9 14 1.7 D
Comments: HCO3: Notified [**Location (un) **] At 1155am On [**2171-6-25**]. Pfr
CK: 2067 MB: 32 MBI: 1.5
Ca: 6.2 Mg: 1.7 P: 4.2
ALT: AP: Tbili: Alb:
AST: LDH: Dbili: TProt:
[**Doctor First Name **]: Lip:
Vit-B12:1051 Folate:19.6
Other Blood Chemistry:
Iron: 8
calTIBC: 186
Ferritn: 304
TRF: 143
95
32.3 10.9 D 214
32.0 D
N:76 Band:16 L:4 M:2 E:0 Bas:0 Metas: 2
Comments:
Neuts: DOHLE BODIES
Anisocy: 1+ Poiklo: 1+ Macrocy: 1+ Burr: 1+
Retic: 1.0
PT: 17.5 PTT: 36.5 INR: 1.6
[**2171-6-25**]
09:40a
pH
7.24 pCO2
40 pO2
52 HCO3
18 BaseXS
-9
Comments: pH: No Calls Made - Not Arterial Blood
Type:[**Last Name (un) **]
[**2171-6-25**]
07:01a
Green Top
Lactate:8.6
Comments: Lactate: Verified
[**2171-6-25**]
05:30a
Color
Yellow Appear
Cloudy SpecGr
1.020 pH
7.0 Urobil
Neg Bili
Neg
Leuk
Mod Bld
Lg Nitr
Neg Prot
100 Glu
Neg Ket
Neg
RBC
[**10-15**] WBC
>50 Bact
Many Yeast
None Epi
[**1-28**]
Other Urine Counts
3PhosX: Many
[**2171-6-25**]
03:51a
pH
7.19 pCO2
41 pO2
51 HCO3
16 BaseXS
-11
Comments: pH: Verified
pH: Provider Notified [**Name9 (PRE) **] [**Name9 (PRE) **] Lab Policy
Type:[**Last Name (un) **]; Green Top Tube
Na:140
K:3.9
Cl:111 Glu:154
Lactate:10.5
[**2171-6-25**]
03:45a
PT: 16.4 PTT: 35.4 INR: 1.5
[**2171-6-25**]
01:50a
135 98 55 163
>10.0 15 3.2
Comments: K: Hemolysis Falsely Elevates K
K: Hemolyzed, Grossly
K: Notified [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-Ed 3:05 A.M. [**2171-6-25**]
estGFR: 20/24 (click for details)
CK: 1178 MB: 12 MBI: 1.0 Trop-T: 0.05
Comments: cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Ca: 8.3 Mg: 2.5 P: 3.5
ALT: 48 AP: 88 Tbili: 0.6 Alb:
AST: 117 LDH: Dbili: TProt:
[**Doctor First Name **]: 614 Lip: 51
Comments: AST: Hemolysis Falsely Increases This Result
97
27.1 15.9 306
47.7
N:72 Band:16 L:4 M:3 E:0 Bas:0 Metas: 5
Poiklo: 1+ Tear-Dr: 1+
Plt-Est: Normal
Comments: Plt-Smr: Large Plt Seen
.
MICROBIOLOGY:
[**2171-6-25**] 3:45 am BLOOD CULTURE **FINAL REPORT [**2171-6-27**]** ([**2-27**]
bottles)
PROTEUS MIRABILIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED FROM
ANAEROBIC BOTTLE.
SENSITIVITIES: MIC expressed in
MCG/ML
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2171-6-25**] 5:30 am URINE Site: CLEAN CATCH
**FINAL REPORT [**2171-6-27**]**
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
.
[**2171-6-25**] 8:08 pm CATHETER TIP-IV Source: Midline.
**FINAL REPORT [**2171-6-28**]**
WOUND CULTURE (Final [**2171-6-28**]):
DUE TO MIXED BACTERIAL TYPES ( >= 3 COLONY TYPES) NO
FURTHER WORKUP
WILL BE PERFORMED.
PROTEUS MIRABILIS. >15 colonies.
Isolate(s) identified and susceptibility testing
performed because
of concomitant positive blood culture(s).
Comparison of the susceptibility patterns may be
helpful to assess
clinical significance.
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
[**2171-6-27**] 2:49 pm BLOOD CULTURE Source: Line-aline.
PENDING......
[**2171-6-28**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING
.
[**2171-6-26**] 3:49 am STOOL
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Final [**2171-6-28**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2171-6-26**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
.
IMAGING:
Head CT [**6-25**]: 1. No acute intracranial hemorrhage. No
significant change compared to CT of [**2171-5-12**] with multiple
chronic findings as described above. 2. Soft tissue density
material within the external auditory canals bilaterally, most
likely cerumen. Correlation with physical exam is recommended.
.
Portable abdomen [**6-25**]: 1. Marked gastric distention. Dilated
nonspecified loops of bowel. Obstruction cannot be excluded. 2.
Suggestion of markedly distended bladder.
.
CT abdomen/pelvis [**6-25**]: Detailed evaluation of the
intra-abdominal and pelvic organs is limited secondary to lack
of intravenous contrast administration and artifact secondary to
patient arm positioning.
1. No acute intra-abdominal or intra-pelvic pathology.
2. Thickening of the rectal and sigmoid walls may be secondary
to chronic use of laxatives. Infectious proctitis and
inflammatory bowel disease also remain in the differential
diagnosis. Vascular etiologies are considered less likely. If
abdominal symptoms persist, consider follow up exam with oral
and IV contrast.
3. Mild bilateral hydronephrosis. Small bladder diverticulum.
4. Diffuse osteopenia with contiguous compression fractures of
the thoracic and lumbar spine as described above of, age
indeterminate, but overall chronic in appearance.
5. Right femoral head subchondral sclerotic line could represent
a stress fracture versus early avascular necrosis.
.
portable CXR [**6-25**]: 1. Right internal jugular central venous line
tip likely terminates in the cavo-atrial junction. 2. Increased
left retrocardiac opacity may represent atelectasis or
consolidation.
portable CXR [**6-26**]: Cardiac silhouette is obscured and is probably
at the upper limits of normal in size. Bibasilar atelectasis and
possible small effusion. No vascular congestion and I doubt the
presence of consolidations. Tip of the right IJ line lies in the
right atrium. Allowing for technical differences, there is
little change from exam 24 hours ago, including the IJ line
placement. Tip of NG tube in stomach.
.
EKG [**6-25**] 2:29 am: Baseline artifact. Sinus tachycardia. Low QRS
voltage in the limb leads. Diffuse T wave flattening which is
non-specific. Compared to tracing of [**2171-5-12**] significant sinus
tachycardia is new. Clinical correlation is suggested.
Rate PR QRS QT/QTc P QRS T
132 118 92 322/400 56 56 57
EKG [**6-25**] 12:29 pm: Sinus tachycardia with slight ST segment
elevations in leads I and aVL. New T wave inversion in leads
V1-V4 with ST-T wave flattening in leads V5-V6. These findings
are consistent with acute anterolateral ischemic process.
Followup and clinical correlation are suggested.
Rate PR QRS QT/QTc P QRS T
108 152 92 364/427.57 30 -5 9
WBC scan - Decision:
Following the injection of autologous white blood cells labeled
with In-111,
images of the whole body were obtained.
These images show no abnormal foci of tracer accumulation.
The above findings are consistent with no radiologic evidence of
any fever
focus.
However, the sensitivity of the study for detection of occult
infection is
decreased by prolonged antibiotic use.
IMPRESSION: No radiologic evidence of any focal fever source
with limitations as
noted above.
PICC change - IMPRESSION: Successful exchange of a previously
placed PICC line over the wire with a new placement of 35 cm
double-lumen line PICC line with tip in the distal part of the
SVC. The line is ready for use.
CXR [**7-22**] - Lung volumes remain quite low. Subsegmental
atelectasis in the left mid lung is unchanged since [**7-16**],
new since [**7-8**]. Upper lungs clear. No pneumonia or
pulmonary edema. Small bilateral pleural effusion may be
present. Heart size normal. Tip of the right PIC catheter
projects over the superior cavoatrial junction.
UPEP - pending
Rib XR- IMPRESSION:
1. Several old healed rib fractures on the right lower inferior
rib cage. The right sixth rib laterally may be acute.
2. A biliary drain identified.
3. Small bilateral pleural effusions and atelectasis at the lung
bases.
LENI bilaterally - CONCLUSION: No evidence of DVT.
CT [**2171-7-14**]: CT OF THE CHEST WITH IV CONTRAST: The heart and
great vessels are unremarkable. There is no pericardial
effusion. No pulmonary nodules or opacities are identified.
There are small, bilateral pleural effusions with associated
atelectasis which are overall unchanged in appearance compared
to [**2171-7-3**].
CT OF THE ABDOMEN WITH IV CONTRAST: The patient is status post
cholecystostomy with a pigtail drain coiled within the
gallbladder fossa in good position. The gallbladder itself is
overall decompressed. There is no evidence of intra- or
extra-hepatic biliary dilatation. The liver is normal in
appearance without focal lesion. The spleen, pancreas, adrenal
glands, stomach and abdominal portions of the large and small
bowel are unremarkable. A small, 3-mm low-attenuation lesion
within the mid pole of the left kidney is too small to
characterize but likely represents a simple renal cyst (2:59).
There are a few, sub 5-mm low-attenuation lesions within the
right kidney which are also too small to characterize but likely
represent simple cysts. There is no free air or free fluid
within the abdomen. No pathologically enlarged mesenteric or
retroperitoneal lymph nodes identified. There are few prominent
mesenteric lymph nodes present.
CT OF THE PELVIS WITH IV CONTRAST: There is mild wall thickening
of the rectum and sigmoid colon which overall is improved in
appearance compared to the previous examination. A Foley balloon
is present within the bladder which is relatively decompressed.
The bladder wall is mildly thickened and this is also unchanged
compared to the previous evaluation. There is no free fluid in
the pelvis. There are no pathologically enlarged inguinal or
pelvic lymph nodes.
OSSEOUS STRUCTURES: Diffuse osteopenia is unchanged. Old
fractures of the right superior and inferior pubic rami are also
unchanged. Contiguous compression fractures of the entire
thoracolumbar spine are present and unchanged. There are no
suspicious lytic or blastic lesions.
IMPRESSION:
1. Status post cholecystostomy with pigtail drain placed within
the gallbladder fossa in good position. No intraabdominal fluid
collections.
2. Stable appearance of bilateral pleural effusions and adjacent
atelectasis.
GB DRAINAGE,INTRO PERC TRANHEP; GUIDANCE PERC TRANS BIL DRAINA
Reason: Place a cholecystostomy tube
[**Hospital 93**] MEDICAL CONDITION:
62 year old man with HIDA scan positive for cholecystitis. Poor
surgical candidate for GB removal and fevers despite antibiotics
REASON FOR THIS EXAMINATION:
Place a cholecystostomy tube
INDICATION: Acute cholecystitis on HIDA scan. Poor surgical
candidate.
COMPARISON: HIDA, [**2171-7-9**].
PROCEDURE/FINDINGS: A prominent dilated gallbladder with a few
intraluminal shadowing stones is appreciated. After explaining
the risks and benefits of the procedure, informed written
consent was obtained. The patient was placed supine on the table
and a timeout was performed to confirm patient name, location,
and procedure. The patient was prepped and draped in the usual
sterile fashion and 1% lidocaine was used for local anesthesia.
Under constant ultrasound guidance, [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 4300**] needle was
percutaneously placed into the gallbladder. An 8 French dilator
was used and an 8 French pigtail catheter was subsequently
threaded into the gallbladder lumen. 100 cc of dark bile was
aspirated and sent for culture.
The patient tolerated the procedure well and there were no
complications. Mild sedation was used including 25 mcg of
Fentanyl IV. The attending, Dr. [**First Name (STitle) **] [**Name (STitle) **], was present and
performed the entire procedure.
Post-procedure orders were placed in CareWeb.
IMPRESSION: Successful ultrasound-guided drainage and catheter
placement within gallbladder.
ECHO - Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or
color Doppler. The estimated right atrial pressure is 0-5mmHg.
Left
ventricular wall thickness, cavity size and regional/global
systolic function
are normal (LVEF >55%) There is no ventricular septal defect.
Right
ventricular chamber size and free wall motion are normal. The
aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no
aortic regurgitation. No masses or vegetations are seen on the
aortic valve.
The mitral valve leaflets are structurally normal. No mass or
vegetation is
seen on the mitral valve. Trivial mitral regurgitation is seen.
There is mild
pulmonary artery systolic hypertension. No vegetation/mass is
seen on the
pulmonic valve. There is no pericardial effusion.
IMPRESSION: No valvular vegetations seen.
PORTABLE CHEST OF [**2171-7-8**].
COMPARISON: [**2171-7-2**].
INDICATION: Fever.
New right PICC line terminates in the superior vena cava.
Cardiac and mediastinal contours are stable in appearance.
Worsening bibasilar retrocardiac opacities are present, probably
related to atelectasis, although underlying infectious process
is not excluded. Small pleural effusions, right greater than
left, are not substantially changed.
MRI L, T spine - IMPRESSION: No evidence of spondylodiscitis or
epidural or paraspinal abscesses of the thoracolumbar spine.
Degenerative changes of the thoracolumbar spine without canal
stenosis.
Partially imaged are degenerative changes of the cervical spine
with likely mild-to-moderate canal stenosis at the C3/4 and C4/5
levels.
Large right pleural effusion.
RIGHT FEMUR ON [**7-6**]
HISTORY: Fever. Possible AVN.
Five views of the upper and lower femur show no abnormality of
the femoral head, neck, trochanteric region are normal. There is
some demineralization of the mid shaft and heterogeneous
mineralization of the condyles of the femur and possibly tibial
plateau. I would recommend routine views of the knee for better
characterization.
KUB [**2171-6-25**] - IMPRESSION:
1. Marked gastric distention. Dilated nonspecified loops of
bowel. Obstruction cannot be excluded.
2. Suggestion of markedly distended bladder.
CT head: IMPRESSION:
1. No acute intracranial hemorrhage. No significant change
compared to CT of [**2171-5-12**] with multiple chronic findings as
described above.
2. Soft tissue density material within the external auditory
canals bilaterally, most likely cerumen. Correlation with
physical exam is recommended.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2171-7-23**] 06:07AM 7.1 2.98* 8.9* 27.6* 93 30.0 32.4 15.0
880*
Source: Line-PICC
[**2171-7-22**] 05:00AM 8.6 2.86* 8.7* 26.5* 92 30.4 32.9 14.6
850*
Source: Line-PICC
[**2171-7-21**] 04:26AM 6.9 2.82* 8.5* 26.0* 92 30.0 32.5 14.5
779*
Source: Line-PICC
[**2171-7-20**] 05:44AM 7.2 2.73* 8.1* 25.6* 94 29.8 31.8 14.4
842*
Source: Line-L PICC
[**2171-7-19**] 06:00AM 7.2 2.74* 8.6* 25.7* 94 31.4 33.4 14.5
806*
Source: Line-PICC
[**2171-7-17**] 03:15PM 8.5 3.09* 9.5* 29.1* 94 30.6 32.4 14.7
975*
Source: Line-PICC
[**2171-7-17**] 06:08AM 7.1 3.10* 9.5* 29.1* 94 30.6 32.6 14.4
873
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos Plasma
[**2171-7-23**] 06:07AM 62 0 23 11 1 2 1* 0 0
MISCELLANEOUS HEMATOLOGY ESR
[**2171-7-15**] 05:47AM 86*
Source: Line-PICC
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2171-7-22**] 05:00AM 105 11 0.6 136 4.1 102 28 10
Source: Line-PICC
[**2171-7-21**] 04:26AM 9 0.6 133 4.1 98 28 11
Source: Line-PICC
[**2171-7-19**] 06:00AM 84 9 0.6 137 4.9 101 30 11
Source: Line-PICC
[**2171-7-17**] 06:08AM 86 10 0.6 131* 4.8 93* 29 14
[**2171-7-15**] 05:47AM 86 7 0.6 138 4.0 103 29 10
Source: Line-PICC
[**2171-7-13**] 12:08AM 78 9 0.6 139 4.3 103 29 11
Source: Line-PICC
[**2171-7-12**] 04:54AM 71 7 0.5 136 3.9 101 27 12
Source: Line-picc
[**2171-7-11**] 05:30AM 91 9 0.7 137 4.3 100 29 12
Source: Line-PICC
[**2171-7-10**] 04:45AM 6 0.6 138 3.8 100 31 11
Source: Line-picc
[**2171-7-9**] 05:32AM 85 5* 0.5 139 3.7 100 32 11
Source: Line-PICC
[**2171-7-8**] 05:27AM 78 5* 0.5 142 3.1* 104 32 9
Source: Line-PICC
[**2171-7-7**] 05:20AM 3* 0.5 141 3.4 102 31 11
Source: Line-PICC
[**2171-7-6**] 12:27PM 78 3* 0.5 141 3.5 103 29 13
Source: Line-PICC
[**2171-7-5**] 06:00AM 76 4* 0.5 140 4.21 103 27 14
SLIGHT HEMOLYSIS
1 HEMOLYSIS FALSELY INCREASES THIS RESULT
[**2171-7-4**] 08:10AM 87 5* 0.6 137 4.2 101 30 10
[**2171-7-3**] 12:50PM 83 8 0.6 137 4.2 99 28 14
[**2171-7-2**] 05:04AM 138* 10 0.7 133 4.0 97 27 13
Source: Line-RIJTLC
[**2171-7-1**] 05:39AM 88 9 0.5 139 3.9 104 32 7*
Source: Line-TLIJ
[**2171-6-30**] 04:21AM 127* 8 0.6 140 4.0 106 29 9
[**2171-6-29**] 05:19AM 79 9 0.5 141 3.1* 105 32 7
Source: Line-R EJ
[**2171-6-28**] 04:25AM 73 14 0.5 142 3.5 109* 26 11
Source: Line-aline
[**2171-6-27**] 02:25PM 88 18 0.5 141 3.9 110* 24 11
Source: Line-PICC
[**2171-6-27**] 04:28AM 77 20 0.6 143 2.9*1 111* 25 10
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2171-7-19**] 06:00AM 54
Source: Line-PICC
[**2171-7-17**] 03:15PM 150 0.4
Source: Line-PICC
[**2171-7-15**] 05:47AM 17 15 68 0.3
Source: Line-PICC
[**2171-7-13**] 12:08AM 20 14 69 0.4
Source: Line-PICC
[**2171-7-12**] 04:54AM 24 14 72 71 0.6
Source: Line-picc
[**2171-7-11**] 05:30AM 30 14 82 88 0.5
Source: Line-PICC
[**2171-7-10**] 04:45AM 35 15 169 85 0.6
Source: Line-picc
[**2171-7-7**] 05:20AM 67* 23 97 72 0.7
Source: Line-PICC
[**2171-7-5**] 06:00AM 98*1 241 232 110 110* 0.7
SLIGHT HEMOLYSIS
1 HEMOLYSIS FALSELY INCREASES THIS RESULT
[**2171-7-4**] 08:10AM 125* 24 102 122* 0.8
[**2171-7-3**] 12:50PM 162* 29 117 162* 0.8
[**2171-7-2**] 09:50AM 207* 30 111 185* 0.7
Source: Line-R IJ
[**2171-6-30**] 04:21AM 374* 65*
[**2171-6-29**] 05:19AM 596* 150* 199 122* 1.4
Source: Line-R EJ
[**2171-6-28**] 04:25AM 890* 334* 213
Source: Line-aline
[**2171-6-27**] 04:28AM 1361*1 896* 314* 87 1.0
Source: Line-aline
1 VERIFIED BY REPLICATE ANALYSIS
[**2171-6-26**] 04:57PM 1759* 1590* 838* 84 0.9
Source: Line-aline
[**2171-6-25**] 05:07PM 2496*1
SLIGHTLY HEMOLYZED
1 VERIFIED BY DILUTION
[**2171-6-25**] 10:20AM 2067*
[**2171-6-25**] 01:50AM 48* 117*1 1178* 88 614* 0.6
Lipase 411 ([**2171-7-2**])
HEMATOLOGIC calTIBC VitB12 Folate Hapto Ferritn TRF
[**2171-7-17**] 03:15PM 378*
Source: Line-PICC
[**2171-6-26**] 04:57PM 179* GREATER TH1 GREATER TH2 GREATER
TH1 138*
Source: Line-aline
1 GREATER THAN [**2163**]
2 GREATER THAN 20 NG/ML
[**2171-6-25**] 10:20AM 186* 1051* 19.6 304 143*
PSa 1
CRP 88
HIV - negative
NEUROPSYCHIATRIC Phenyto
[**2171-7-1**] 05:39AM 13.5
Source: Line-TLIJ
[**2171-6-25**] 01:50PM 9.4*
DIL ADDED 2:32PM; SLIGHTLY HEMOLYZED SPECIMEN
TOXICOLOGY, SERUM AND OTHER DRUGS Carbamz
[**2171-7-1**] 05:39AM 6.6
Source: Line-TLIJ
[**2171-6-25**] 02:20PM 2.4*
GENERAL URINE INFORMATION Type Color Appear Sp [**Last Name (un) **]
[**2171-7-18**] 08:50PM Yellow Clear 1.014
Source: Catheter
[**2171-7-14**] 12:25PM Straw Clear 1.010
Source: Catheter
[**2171-7-5**] 09:03PM Straw SlHazy 1.005
Source: Catheter
[**2171-6-25**] 05:30AM Yellow Cloudy 1.020
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone
Bilirub Urobiln pH Leuks
[**2171-7-18**] 08:50PM TR NEG TR NEG NEG NEG NEG 6.5 NEG
Source: Catheter
[**2171-7-14**] 12:25PM TR NEG NEG NEG NEG NEG NEG 8.0 NEG
Source: Catheter
[**2171-7-5**] 09:03PM TR NEG NEG NEG NEG NEG NEG 7.0 NEG
Source: Catheter
[**2171-6-25**] 05:30AM LG NEG 100 NEG NEG NEG NEG 7.0 MOD
MICROSCOPIC URINE EXAMINATION RBC WBC Bacteri Yeast Epi TransE
RenalEp
[**2171-7-18**] 08:50PM 0 2 NONE NONE 0
Source: Catheter
[**2171-7-14**] 12:25PM 2 0 OCC NONE <1
Source: Catheter
[**2171-7-5**] 09:03PM 0 6* NONE NONE 0
Source: Catheter
[**2171-6-25**] 05:30AM [**10-15**]* >50 MANY NONE [**1-28**]
URINE CRYSTALS 3PhosX
[**2171-6-25**] 05:30AM MANY
OTHER URINE FINDINGS Mucous
[**2171-7-14**] 12:25PM RARE
Source: Catheter
MISCELLANEOUS URINE Eos
[**2171-7-14**] 12:25PM NEGATIVE 1
Source: Catheter
1 NEGATIVE NO EOS SEEN
[**2171-7-9**] 05:34PM POSITIVE 1
Source: Catheter
1 POSITIVE RARE EOS
Chemistry
URINE CHEMISTRY Hours UreaN Creat Na TotProt Prot/Cr
[**2171-7-17**] 03:15PM RANDOM 86 100 1.2*
Source: Catheter
[**2171-6-25**] 01:00PM RANDOM 246 17 93
[**2171-6-25**] 05:30AM RANDOM
OTHER URINE CHEMISTRY U-PEP IFE Osmolal
[**2171-7-17**] 03:15PM MULTIPLE P1 NO MONOCLO2
Source: Catheter
1 MULTIPLE PROTEIN BANDS SEEN, WITH ALBUMIN PREDOMINATING
BASED ON IFE (SEE SEPARATE REPORT),
NO MONOCLONAL IMMUNOGLOBULIN SEEN
NEGATIVE FOR BENCE-[**Doctor Last Name **] PROTEIN
INTERPRETED BY [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19695**], MD
2 NO MONOCLONAL IMMUNOGLOBULIN SEEN
NEGATIVE FOR BENCE-[**Doctor Last Name **] PROTEIN
INTERPRETED BY [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19695**], MD
[**2171-6-25**] 01:00PM 308
Time Taken Not Noted Log-In Date/Time: [**2171-7-22**] 4:28 pm
CATHETER TIP-IV RIGHT PICC TIP.
**FINAL REPORT [**2171-7-24**]**
WOUND CULTURE (Final [**2171-7-24**]): No significant growth.
Brief Hospital Course:
#Urosepsis - ICU course: On presentation the patient met
criteria for SIRS and sepsis: WBC of 27, tachycardic and a
source of infection, thought to be most likely urosepsis given
frank pus drainage from the bladder, history of recurrent
infections and his foley found to be obstructed. In review of
past culture data, UTIs in the past have grown pansensitive E.
Coli and ESBL resistant klebsiella previously sensitive to
meropenem, imipenem, zosyn. Per nursing home report, urine
cultures from 3 days PTA grew VRE (sensitivities unknown) and
proteus. He has also had multiple wound swabs that revealed MRSA
and pseudomonas, thus, it was thought also reasonable to
initially cover for MRSA. His wounds, however, do not appear to
be infected and were thought unlikely to be a contributing
source of sepsis. The CT of the abdomen did not appear
consistent with bowel ischemia, but the patient was initially
started on flagyl given colonic thickening. Upon arrival to the
ICU, his CVP initially was [**7-4**], on a dopamine, levophed and
vasopressin drip. A cortisol stimulation test was negative for
adrenal suppression. With input from ID, the patient was started
on meropenem and daptomycin and flagyl was continued. We were
able to wean the dopamine to off on day 1 in the ICU, and
levophed and vasopressin were weaned on day 2. CVP was
maintained between [**7-5**] with 500cc LR boluses on day 3, and the
patient did not require additional boluses on day 4. By day 4 he
was assessed as stable, recovering from the septic picture, and
fit to be called out to the floor. Blood cultures grew GNRs
which were identified as proteus on day 3 (sensitivities above)
([**2171-6-27**]). Based on sensitivities, IV meropenem was continued and
Daptomycin was discontinued.
On the floor, meropenem was continued. However he started having
fevers again and hence flagyl was restarted. Multiple tests done
to identify source of infection - MRI spine - no abscess or
osteomyelitis, ECHO no IE. Cultures neg. no C diff. No PICC
infection, Foley changed. ID was consulted and CT abd, HIDA done
that confirmed acute cholecystitis. Surgery deemed the patient a
poor surgical candidate and hence a cholesystostomy tube was
placed by IR. Abx were changed to aztreonam. WBC scan prior to
dc was normal. Patient finally remained afebrile for > 4 days
prior to discharge. He is to complete a 2 wk course of IV
aztreonam - day 1 [**2171-7-15**]. Flagyl was stopped after about a 3 wk
course. Patient advised a follow up appointment with Dr
[**Last Name (STitle) 4020**] from infectious disease in 2 weeks as well as on
[**2171-7-26**] - patient should get a CBC, chem 7 for monitoring and
results to be faxed as stated below to Dr [**Last Name (STitle) 4020**] who will
check the results. Brief Ca work up as a fever source (PSA,
SPEP, UPEP) normal.
Acute retention of urine was resolved after foley was placed.
Patient may be advised if an SPC is desired to see Dr [**Last Name (STitle) 770**] in
clinic given recurrent UTIs and [**Last Name (STitle) 27285**] obstruction due to MS.
[**Last Name (STitle) **] disorder: The patient had a tonic-clonic [**Last Name (STitle) 862**] on the
first night of admission, that resolved spontaneously within 2
minutes. This was likely exacerbated by his septic state. His
phenytoin and carbamazapine levels were normal. He has been
[**Last Name (STitle) 862**]-free since then. He was maintained on his outpatient
doses of phenytoin and carbamazapine.
After a speech and swallow evaluation, his diet was advanced as
below. Regular diet per second swallow evaluation.
Acute renal failure: Baseline creatinine is 0.4-0.9. Initial
bump in creatinine most likely was secondary to obstruction, but
also given hemoconcentration and response to fluids, appeared to
be prerenal as well. Given frank pus from bladder, ascending b/l
pyelo was a concern, but CT A/P, albeit without contrast, did
not show evidence of this. Creatinine back to baseline 2-3 days
after initiation of volume resuscitation.
Coagulopathy: INR was elevated to 1.5, then 2.2 in the absence
of blood thinning agents. Given his poor nutritional status, may
be a result of vit K deficiency, but certainly was concerning in
the setting of sepsis. Platelet count was normal. D-dimer
decreasing steadily, stable fibrinogen reassuring that DIC is
unlikely.
- INR normalized with 3 daily doses of vitamin K
.
# EKG changes: T wave inversions in septal leads most likely
reflected lead placement, but new from most recent EKG. MB index
negative x2. Ruled out for MI by cardiac enzymes, cardiac
ischemia was unlikely. No events were seen on tele during the
ICU stay. Patient remained CP free.
.
# Elevated LFTs: Initially the process could be related to the
sepsis. However, later he did have acute cholecystitis refer
above. LFT continued to trend down during admission. Normal at
discharge.
# Pancreatitis attributed to Ileus from MS - developed slight
elevation of lipase in setting of ileus attributed to MS. Made
NPO for two days. Repeat CT abdomen without evidence of
pancreatitis, but GB distension and edema with stones. Diagnosed
with cholecystitis as above. Golytely given 2 L per day for two
days with tap water enemas twice daily for two days. Ileus was
aggressively treated and resolved. No acute mech bowel
obstruction was noted.
# Facial rash consistent with fungal infection - stated
miconazole cream.
# Noted anemia and thrombocytosis both of which were stable at
discharge. Please recheck another CBC in a month to be deferred
to the PCP.
Patient has a new PICC dated [**2171-7-22**] and to complete aztreonam
as above. To make appt with IR for biliay drain removal as
below. ID, surgery to follow up.
Medications on Admission:
Meropenem 500 mg IV Q6H
Bisacodyl 10 mg PO/PR DAILY:PRN
Carbamazepine 200 mg PO QID
Docusate Sodium (Liquid) 100 mg PO BID
Pantoprazole 40 mg IV Q24H
Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN
Phenytoin 100 mg PO TID
Heparin 5000 UNIT SC TID
Phytonadione 5 mg PO DAILY
Insulin SC (per Insulin Flowsheet)
Senna 1 TAB PO BID
Lorazepam 2 mg IV PRN [**Month/Day/Year 862**]
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
2. Phenytoin 100 mg/4 mL Suspension Sig: Four (4) mL PO TID (3
times a day).
3. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever.
5. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day): to the face rash.
6. Lorazepam 2 mg/mL Syringe Sig: Two (2) mg Injection PRN (as
needed) as needed for [**Hospital1 862**]: [**Name8 (MD) **] MD [**First Name (Titles) **] [**Last Name (Titles) 862**].
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day): hold for diarrhea.
10. Polyethylene Glycol 3350 17 g (100%) Powder in Packet Sig:
One (1) Powder in Packet PO hs (): hold for diarrhea.
11. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
12. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO QAM (once a day (in the
morning)) as needed for constipation.
14. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
16. Aztreonam 1 g Recon Soln Sig: One (1) Recon Soln Injection
Q8H (every 8 hours): last day [**2171-7-30**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Bacteremia (Proteus sp.) due to [**Location (un) 27285**] tract infection
Acute [**Location (un) 27285**] retention
Fevers from acute cholecystitis
Ileus
Pancreatitis
Seizures
Thrombocytosis
Anemia of chronic disease
Delerium
Transaminitis
Acute renal failure
Multiple sclerosis
Discharge Condition:
Stable
Discharge Instructions:
Return to the hospita;l if you develop fevers, chills, abdominl
pain, vomiting, nausea or any other symptoms of concern to you.
You will have to complete a course of IV antibiotics for the
gall bladder infection.
Dr [**Last Name (STitle) 1699**] - your primary doctor will further care for your
medical needs.
Followup Instructions:
Your PCp [**Name Initial (PRE) **] [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 608**] to follow up at the
NH.
Urology - Dr [**Last Name (STitle) 770**] : [**Telephone/Fax (1) 2906**]- please call to schedule
appointment for a SPC
[**Last Name (LF) **], [**First Name3 (LF) **]: RADIOLOGY: [**Telephone/Fax (1) 5546**]. Call after
anibiotics is completed for removal of the biliary drain.
Surgery - Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6633**] - Dial # : [**Telephone/Fax (1) 2998**] . Please
call to make a follow up appointment in the next 2-3 weeks.
ID - Dr [**First Name8 (NamePattern2) 59674**] [**Last Name (NamePattern1) 4020**] - Call [**Telephone/Fax (1) 457**] to make an
appointment in next 2 weeks for follow up. Fax the results of
CBC, chem 7 to Dr [**Last Name (STitle) 4020**] on [**2171-7-26**] at [**Telephone/Fax (1) 1419**].
|
[
"5990",
"5180",
"5119",
"5849",
"2762",
"2875"
] |
Admission Date: [**2137-3-24**] Discharge Date: [**2137-4-29**]
Date of Birth: [**2083-2-26**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Fatigue, DOE, increasing jaundice
Major Surgical or Invasive Procedure:
Central Venous Line Placement
PICC placement
Intubation
Mechanical Ventilation
History of Present Illness:
54 year old female with HCV cirrhosis, esophageal varices by EGD
who presents with fatigue, dyspnea mostly with exertion,
increasing abdominal girth and jaundice. Pt has h/o hepatitis C
complicated by cirrhosis, portal hypertension, splenomegaly,
ascites. She was recently in [**State 4565**] for her brother's
funeral and had some dietary indiscretions with increased
protein. Family noticed she was more forgetful and she notes
that she had asterixis and stopped eating protein at that point.
She was never disoriented per her report and gave the euology at
her brother's funeral. Before she left she noted that her
abdomen was bigger and she occaisionally has RUQ pain. She notes
decreased BM despite taking lactulose and rifaximin as
prescribed. No nausea or emesis. No fevers/chills. Denies melena
or hematochezia. Also reports some mild dyspnea on exertion
without chest pain, fever or cough. She has also been having her
muscle spasms which respond to flexeril.
In the ED, patient's initial vs were: T 97.4 P 70 BP 116/56 R
22, O2 sat 100% RA. She was given a liter of NS. Liver was
contact[**Name (NI) **]. She had a RUQ u/s with dopplers that just showed
retrograde flow through portal vein but no obstruction and
stable cirrhosis. She also was found to be hyperkalemic w/o ekg
changes and was given kaexylate and dextrose/insulin. She has a
left EJ for access, IJ attempted per note but unsuccessful.
On admission to the floor, she feels well. Denies dizziness, cp,
sob at rest, abdominal pain, feels thirsty. Initial vs on floor
were: 97.9 102/68 70 20 99% RA. ROS as above, except patient
noted dysphagia over the past few years has difficulty
swallowing solid foods, no sore throat but sensation that food
is getting stuck. Had egd [**8-22**] with nothing in upper esophagus.
Past Medical History:
HCV cirrhosis complicated by ascites and edema, + history of
encephalopathy, + hepatopulmonary syndrome - on transplant list
Esophageal varices by EGD on [**6-22**], grade I
Gastric ulcer diagnosed by EGD on [**6-22**], resolved
H. Pylori
Muscle Spasms
Liver Transplant [**2137-4-8**]
Biliary stent [**2137-4-25**]
Social History:
Home: Lives with son in [**Name (NI) 3615**]. Son staying with her
friend.
Occupation: [**Name2 (NI) **] on medical leave.
Remote tobacco history.
Social alcohol ([**3-19**]/wk), none for 3 years.
Denies drug use.
Family History:
Mother - HTN
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.9 102/68 70 20 99% RA.
HEENT: NCAT, + scleral icterus, PERRLA, EOMI, OP clear, MM dry
NECK: supple, no LAD, no bruits
COR: 2/6 sem L and RUSB no radiation
PULM: cta b/l
ABD: +bs, soft, distended, nontender, liver edge 3-4 cm below
rcm
EXTREM: +1 pitting edema b/l
Skin: jaundice, no rashes
Neuro: A/O x3, no asterixis, nonfocal
Pertinent Results:
ADMISSION LABS:
================
WBC-12.2*# RBC-3.41* HGB-12.2 HCT-35.2* MCV-103*
NEUTS-77.7* LYMPHS-9.4* MONOS-10.2 EOS-2.4 BASOS-0.4
PLT COUNT-120*
RET MAN-2.8*
PT-24.2* PTT-49.1* INR(PT)-2.4*
ALT(SGPT)-82* AST(SGOT)-157* ALK PHOS-147* TOT BILI-29.5*
LIPASE-153*
ALBUMIN-2.7*
LD(LDH)-308* DIR BILI-18.6*
[**2137-4-29**] 06:35AM BLOOD WBC-6.5 RBC-3.09* Hgb-9.4* Hct-28.1*
MCV-91 MCH-30.5 MCHC-33.6 RDW-16.4* Plt Ct-183
[**2137-4-28**] 06:00AM BLOOD WBC-6.1 RBC-3.03* Hgb-9.2* Hct-27.0*
MCV-89 MCH-30.4 MCHC-34.1 RDW-16.2* Plt Ct-158
[**2137-4-28**] 06:00AM BLOOD PT-13.9* PTT-26.4 INR(PT)-1.2*
[**2137-4-29**] 06:35AM BLOOD Glucose-85 UreaN-17 Creat-1.0 Na-135
K-4.1 Cl-98 HCO3-29 AnGap-12
[**2137-4-28**] 06:00AM BLOOD ALT-23 AST-12 AlkPhos-395* TotBili-2.3*
[**2137-4-29**] 06:35AM BLOOD ALT-19 AST-10 AlkPhos-338* TotBili-2.1*
[**2137-4-29**] 06:35AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.1*
[**2137-4-28**] 06:00AM BLOOD FK506-10.9
Brief Hospital Course:
54 yo F admitted with HCV cirrhosis, on transplant list, here
for fatigue and increasing jaundice found to be hyponatremic and
hyperkalemic with progressively rising bilirubin and INR,
worsening hepatic function, MELD of 48. She was admitted to the
MICU where she was intubated for airway management secondary to
continued
decompensation. She was placed on a free water restriction,
diuretics were held, albumin 25g [**Hospital1 **], octreotide and midodrine
were given.
Baseline HCT was in 30s then decreased to the low to mid 20s.
Stool was guaiac positive. There was concern for slow GI bleed
given portal gastropathy, grade I varices and a healed gastric
ulcer. She received FFP and PRBC.
On [**4-8**] a liver donor was available from a CDC high risk donor.
This donor did have NAT testing that was negative for HCV, HIV
and HBV. Her HIV, HBV, HCV serology were also negative. She
underwent orthotopic deceased donor liver transplant
(piggyback), portal vein to portal vein anastomosis, common bile
duct to common bile duct anastomosis(no T tube), common hepatic
artery (donor) to proper hepatic artery (recipient) end-to-end.
Surgeon was Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]. Please see operative report
for complete details. Two JP drains were placed. EBL was
10,000cc. She received 27 units of PRBC, crytalloid, cryo, ffp,
and cellsaver. She received standard induction immunosuppression
consisting of solumedrol and cellcept. Immediately postop, she
was transferred intubated to the SICU. She was febrile to 101
postop. Blood cultures drawn which were negative. The PICC line
was removed and the tip cultured. This culture was negative. She
continued to receive blood products. JPs were draining ~100cc
each with serosang fluid.
On POD 1 a duplex liver US showed the hepatic veins and portal
veins to be patent with normal waveforms. The main hepatic
artery and intrahepatic arterial branches were patent, although
mild reduction of diastolic flow was noted. There were no
peri-transplant fluid collections and there was no intra- or
extra-hepatic biliary ductal dilation. Prograf was started. LFTS
slowly trended down.
On pod 2, she was extubated without incident. A CXR showed
volume overload. A lasix drip was given. Repeat CXR showed
improvement. She was slow to wake up and had mild confusion.
Pain medication was adjusted. Diet was advanced slowly and
tolerated although appetite was poor.
The lateral JP was removed on pod 6. PT evaluated and
recommended rehab. She tended to desat to the mid 80s off O2
when ambulating. Nasal cannula O2 was continued. Aggressive
diuresis with lasix continued for postop weight that was up
10-15kg from preop. Breath sounds were decreased in the right
base.
On pod 5, a repeat liver duplex showed similar findings as on
pod 1 with mild reduction of diastolic flow noted.
Alk phos trended up daily to 433 on [**4-22**] from pod 1 of 106.
T.bili continued to trend down to 3.0 from 16 immediately
postop. A liver biopsy was performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] after
US marking. Biopsy demonstrated no rejection and features were
consistent with mild resolving ischemic/reperfusion injury. Post
biopsy, vital signs remained stable and a post biopsy HCT was
stable. The medial JP was removed.
Alk phos continued to increase and an ERCP was performed on
[**4-25**]. This demonstrated sharp angulation at the level of duct to
duct anastomosis without definitive stricture or filling defects
identified. Mild duct dilation was noted proximal and distal to
the anastamosis. A stent was placed. She tolerated this
procedure well without complications. On [**4-26**], the alk phos was
584 and t.bili was 2.7. Alk phos continued to slowly trend
down. Ursodiol was not ordered given potential GI side effects
with her present complaints of indigestion.
Cellcept was changed to [**Hospital1 **] for complaints of indigestion.
Solumedrol was tapered to prednisone. Prednisone was further
tapered to 17.5mg and prograf was titrated to 2mg [**Hospital1 **] for
trough levels of [**10-26**].
IV lasix was changed 20mg po qd. Edema had decreased
considerably.
She was discharged to [**Hospital **] Rehab on [**4-29**] in stable condition
with AVSS, tolerating a regular diet and ambulatory.
Medications on Admission:
1. Cyclobenzaprine 2.5 mg [**Hospital1 **]
2. Quinine Sulfate 324 mg PO HS
3. Citalopram 20 mg PO DAILY
4. Lactulose 30 ml PO TID
5. Clotrimazole 10 mg five times per day
6. Calcium Carbonate 600 mg PO BID (doesnt always take)
7. Magnesium Oxide 400 mg PO QD (doesnt always take)
8. prilosec 20 mg qd
9. Furosemide 40 mg PO DAILY (recently decreased)
10. Spironolactone 100 mg PO DAILY
11. Rifaximin 600 mg [**Hospital1 **]
12. Nadolol 20 mg qd
MEDICATIONS ON TRANSFER TO MICU:
1. Octreotide Acetate 100 mcg SC Q8H
2. Midodrine 10 mg PO TID
3. Lactulose 30 mL PO TID
4. Rifaximin 600 mg PO BID
5. Albumin 25% (12.5g / 50mL) 25 gm IV BID
6. CeftriaXONE 1 gm IV Q24H
7. Citalopram Hydrobromide 20 mg PO DAILY
8. Acetaminophen 500 mg PO Q6H:PRN
9. Pantoprazole 40 mg PO Q12H
10. Calcium Carbonate 500 mg PO BID
11. Sarna Lotion 1 Appl TP QID:PRN
12. Clotrimazole 1 TROC PO 5X/DAY
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection four times a day.
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
7. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4H
(every 4 hours) as needed.
10. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
14. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
15. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
HCV cirrhosis
Liver transplant
Biliary anastomosis angulation with ductal dilatation
s/p ercp stent placement
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
jaundice, edema, shortness of breath or incision redness,
bleeding or drainage
Labs every Monday and Thursday
Followup Instructions:
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2137-5-8**] 9:40
Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] [**Telephone/Fax (3) **] on [**2137-5-14**] at 9:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2137-4-29**]
|
[
"5849",
"2761",
"5990",
"51881",
"2767",
"2875"
] |
Admission Date: [**2121-4-13**] Discharge Date: [**2121-4-15**]
Date of Birth: [**2076-3-16**] Sex: M
Service: MEDICINE
Allergies:
Cephalosporins / Demerol / Morphine
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Head/neck/chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 45 yo male with [**First Name3 (LF) 14165**] cell disease who woke up with
head, neck and chest pain, at 3-4am. He took two Percocet and
drank a lot of water. The pain would not subside, so he came to
the ED. He denied any F/C, no N/V/D, no CP, SOB. He does admit
to tightness with breathing which is now resolved. His pain was
along the posterior neck and skull. He rated it at a [**10-27**], now
a [**6-27**]. He has had pain in neck and head before, but his pain is
typically in his joints. Of note, he was last admitted to [**Hospital1 18**]
in [**7-/2120**] with chest pain, felt to be acute chest syndrome vs
PNA, treated with pain control, IVF, oxygen and levofloxacin.
.
He denies any recent illnesses and says that he tries to keep up
on his fluids. He drinks a lot of water. However, he's been
unable to make doctors [**Name5 (PTitle) 4314**] secondary to being busy with
work. He says that his pain crises have started to occur once
every 2 weeks for which he takes tylenol, then percocet if
needed.
.
In the [**Hospital1 18**] ED, initial VS were: 98.8 76 124/77 17 100%. EKG,
CXR and head CT unremarkable. Labs showed hct 14, from baseline
23. He is being crossed for 2 units pRBCs and will then be
transfused. He was also given 2L IVF and 1mg hydromorphone, with
improvement in pain. Heme-onc was notified of admission.
Initially going to medicine floor, but changed to ICU given
concern over low hct with chest pain. Vitals on admission: 98.7
65 115/85 16 100,2L.
.
On the floor, he is lying in bed in NAD, comfortable, though
rating his pain at a [**6-27**].
.
Review of systems:
(+) Per HPI, and headache, shortness of breath, palpitations,
urinary retention, and arthralgias .
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies cough. Denies chest pain, chest pressure, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies rashes or skin changes.
Past Medical History:
[**Month/Year (2) **] Cell Disease
Hepatitis C, contracted by blood transfusion in childhood
Peptic Ulcer Disease
GERD
Asthma
BPH with urinary retention
Gallstones s/p cholecystectomy
Chronic tonsillitis
Mild pulmonary arterial hypertension, on 2L O2 at night
Social History:
Patient works at the Red Cross 6 [**Last Name (un) 32460**] a week. He lives alone in
[**Location (un) 686**]. He is currently separated from his wife who lives
with his 2 daughters (8yo and 11yo). He drinks no EtOH, no
tobacco, no illicit drugs.
Family History:
Mother with breast cancer. Father passed from an MI. His brother
and sister are both healthy. He has two daughters without [**Name2 (NI) 14165**]
cell disease.
Physical Exam:
Vitals: T: 98 BP: 99/76 P: 75 R: 16 O2: 100% on 2L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, pale
conjunctiva and mucous membranes
Neck: supple, JVP not elevated, no LAD, TTP along the paraspinal
muscles of the cervical spine
Lungs: Clear to auscultation bilaterally, with very few
interspersed crackles, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: Pale palms, and nailbeds, warm, well perfused, 2+ pulses,
no clubbing, cyanosis or edema
Neuro: 5/5 strength, CN II/XII in tact grossly
Pertinent Results:
Admission Labs:
[**2121-4-13**] 08:20AM BLOOD WBC-3.1* RBC-1.17*# Hgb-5.4*# Hct-14.3*#
MCV-122* MCH-46.1*# MCHC-37.9*# RDW-19.8* Plt Ct-197#
[**2121-4-13**] 08:34AM BLOOD PT-12.9 PTT-29.3 INR(PT)-1.1
[**2121-4-13**] 08:20AM BLOOD Glucose-100 UreaN-19 Creat-0.8 Na-134
K-4.3 Cl-103 HCO3-26 AnGap-9
Imaging:
CT HEAD W/O CONTRAST Study Date of [**2121-4-13**] 8:31 AM
IMPRESSION: No acute intracranial process.
[**2121-4-15**] 09:00AM BLOOD WBC-3.4* RBC-2.27* Hgb-8.3* Hct-22.6*
MCV-100* MCH-36.7* MCHC-36.9* RDW-24.3* Plt Ct-184
[**2121-4-14**] 09:30AM BLOOD WBC-3.6* RBC-2.38* Hgb-8.7* Hct-23.4*
MCV-98# MCH-36.5* MCHC-37.1* RDW-24.9* Plt Ct-162
Brief Hospital Course:
45 year old male with a PMH of [**Month/Day/Year 14165**] cell disease, hep c, and
PAH, who presents with pain crisis found to have a HCT of 14.
# SICKE CELL DISEASE -- crisis. He was managed with pain meds,
iv fluids. Attribute crisis to likely viral precipitant. No
fever. No CP during admission. Pain is in his neck and back of
his skull. He has had crises with this presentation in the past
though arthralgias are more common. Continued on home dose folic
Acid and Fish Oil. He was given 1L NS on transfer to ICU.
Parvovirus B19 antibody pending at time of transfer from ICU
showed he's been exposed in the past but does not have acute
infection.
.
#ANEMIA -- Attributed to [**Month/Day/Year 14165**] cell crisis. Transfused to goal
>20. Baseline around 20. He sees Dr. [**Last Name (STitle) **] in the hematology
department. He had no signs of overt bleeding. Etiology of
anemia secondary to pain crisis or hydroxyurea. Transfused 4u
pRBC total during stay.
.
# NECK PAIN -- improved. Attributed to [**Last Name (STitle) 14165**] cell crisis. Head
CT was negative.
Medications on Admission:
ALBUTEROL - 90 mcg inh QID prn
FOLIC ACID - 5 mg daily
HYDROXYUREA - [**2110**] mg daily
LEVOFLOXACIN - 750 mg prn T>=100.4
OXYBUTYNIN - 10 mg daily
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1-2 tabs q6h prn
OMEGA-3 FATTY ACIDS - (OTC) - Dosage uncertain
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. oxybutynin chloride 5 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. hydroxyurea 500 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
7. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-23**]
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. oxygen Sig: Two (2) L/min Nasal Continuous: Use as directed:
Continuous for portability pulse dose system.
Disp:*1 * Refills:*99*
Discharge Disposition:
Home
Discharge Diagnosis:
[**Month/Day (3) **] Cell crisis
Anemia
Pulmonary Hypertension
Chronic Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with acute anemia from [**Month/Day (3) 14165**] cell crisis and
received blood transfusions with good response. You have
pulmonary hypertension for which oxygen is recommended at night
and as needed. You did not arrange to have this supplied for
the last 6-7 months, but you are now referred again for this
(you are given portable O2 to go home and instructions from O2
company on who to contact when you are home to get home O2
delivered -- please do this). You should followup to establish
care with your new PCP as below. Please continue adequate
hydration at home.
Followup Instructions:
Department: [**Hospital3 249**]
When: THURSDAY [**2121-5-1**] at 2:15 PM
With: [**Name6 (MD) 2620**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"4168",
"53081",
"49390"
] |
Admission Date: [**2129-1-10**] Discharge Date: [**2129-1-20**]
Date of Birth: [**2058-3-17**] Sex: M
DIAGNOSIS: Status post excision of glioblastoma multiforme,
status post craniotomy.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 7518**] is a 70-year-old
a 70-year-old gentleman with a past medical history
significant for diverticulitis and hyperlipidemia. According
to his wife, he had mental status changes in [**Month (only) **] and
[**Month (only) **]. He was seen by his primary care physician where he
had polyuria, polyphagia, and polydipsia. He also described
incontinence, unsteady gait, and mental status changes. He
was scheduled for a CT scan of the brain on [**12-29**] which
admitted to the hospital for further treatment.
At [**Hospital3 1280**] Hospital he had a stereotactic biopsy of the
right temporal mass on [**1-3**] with a tissue diagnosis of
high-grade glioblastoma multiforme. He was transferred to
[**Hospital1 69**] for craniotomy and
excision of tumor on [**1-10**].
MEDICATIONS ON ADMISSION: His present medications were NPH
insulin 20 units in the morning and evening, sliding-scale
regular insulin, ProMod with fiber via the nasogastric tube
with a goal of 75 cc, Dilantin 100 mg per nasogastric tube
b.i.d., nitroglycerin past 2 inches to chest (which should be
held if systolic blood pressure is less than 100),
Prevacid 30 mg per nasogastric tube q.d., Tylenol 650 mg per
nasogastric tube q.4-6h. p.r.n., dexamethasone 20 mg
intravenously q.6h., Colace 100 mg t.i.d., hydralazine 40 mg
per nasogastric tube q.6h., Lopressor 50 mg per nasogastric
tube b.i.d.
PHYSICAL EXAMINATION ON PRESENTATION: On examination, he was
awake and alert, and he was speaking but was disoriented to
month and time and place consistently. Pupils were equal,
both were postsurgical, reactive from 3 to 2.5. Extraocular
muscles were intact. No nystagmus. No diplopia. No visual
field deficits. No facial asymmetry. His left upper
extremity showed a mild pronator drift. Plantars were
withdrawn. There was no sensory deficits. Proprioception
was intact.
HOSPITAL COURSE: The morning after admission his mental status
was worse and he was quite obtunded.MRI was done for the
stereotactic procedure. He underwent craniotomy on [**1-11**].
Prior to the craniotomy, there was a gradual change in mental
status where he was progressively more asleep. This was treated
with a dose of Decadron 20 mg intravenously and also followed
by mannitol.
In the immediate postoperative period, Mr. [**Known lastname 7518**] was
found to be more poorly responsive compared to the
preoperative period. He was admitted to the Neurosurgery
Intensive Care Unit for close monitoring, and he stayed there
for 72 hours, after which he was transferred to the floor.
Hewas given high-dose decadron, 20 mg q 6h.
CONDITION AT DISCHARGE: Mr. [**Known lastname 7518**] had waxing and [**Doctor Last Name 688**]
levels of consciousness. He awakened to brisk stimuli and
followed commands inconsistently. He did show he could
follow very simple commands like showing two fingers, and
trying to mumble his name, and attempts to wiggle his toes.
DISCHARGE PLAN: The plan was to continue the Decadron at the
same dose of 20 mg p.o. q.6h. for the moment and continue
with the antacid prophylaxis. We are arranging transfer to
a Transitional Care Unit in
[**Hospital 47**] Hospital where he will need PEG placement as he is
unable to feed orally, and at present he has a nasogastric
tube.
[**Known firstname 1569**] [**Last Name (NamePattern4) 9923**], M.D. [**MD Number(1) 9924**]
Dictated By:[**Name8 (MD) 37363**]
MEDQUIST36
D: [**2129-1-20**] 11:07
T: [**2129-1-20**] 11:22
JOB#: [**Job Number 37364**]
|
[
"25000",
"2724"
] |
Admission Date: [**2179-8-27**] Discharge Date: [**2179-8-29**]
Date of Birth: [**2102-10-24**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Gross hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Primary oncologist: Dr. [**First Name (STitle) 1557**]
.
PCP: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 2491**] [**Last Name (NamePattern1) 51490**] ([**Hospital1 **])
.
76M h/o CLL (dx in [**2165**], s/p splenectomy and chemo, last dose on
[**7-21**]), DM, HTN, BPH s/p TURP and indwelling foley, PAF on
coumadin presented with gross hematuria, found to have an INR of
13.4. Patient woke up this morning at 4AM and noticed gross
blood in his foley bag. He also felt that his urine has been
more dark over the last few days. He denies any pain but noted
several small clots passing through. He denies any recent
dizziness or fainting. He is s/p TURP in [**2177**] which was
incomplete. He developed recently UTIs and was started about two
months ago on chronic Bactrim for prophylaxis. In addition, he
was also recently admitted at [**Hospital1 18**] (from [**Date range (1) 51491**]) for febrile
neutropenia after his last dose of chemo on [**7-21**] and was found
to have a LLL pneumonia and E. coli UTI. He was treated with
cefepime, vanco and caspofungin, then discharged on
posiconazole, levofloxacin (for 5 more days after discharge) and
bactrim. His INR on discharge was 1.7 and he was discharged on
15mg daily of Warfarin (as opposed to his usual dose of
19mg/20mg alternating). His last INR in OMR was 1.3 on [**8-6**].
However, the patient was followed by his PCP who increased his
dose back to his 19mg/20mg alternating after outpatient INR
checks. In addition, he was recently admitted at
[**Hospital1 **] for a fainting episode and was found to have a
UTI again. He was discharged on Ciprofloxacin about two weeks
ago which he took since then.
.
After the episode of gross hematuria, the patient went to the
ED. He still had gross hematuria at this point. His VS were
stable (139/83, 100, 18, 98.3, 95%RA). He was found to have an
INR of 13.4, received vitamin K 10mg sc x1, 2x FFP and 1U of
pRBC after his Hct came back with 22 (baseline 24-29). He was
guaiac positive on exam. An NGT was placed and a lavage came
back clear. In addition, a CXR revealed LLL pneumonia and he was
given one dose of Ceftriaxone and Azithromycin. Urology saw the
patient in the ED and recommended bladder flushes until his
urine clears completely. He was admitted for further monitoring.
.
On ROS, the patient denies any CP, abdominal pain, bloody
stools, F/C but 1x nightsweats last Sunday. No SOB, but chronic
mildly productive cough for several months (occasional clear to
whitish sputum).
Past Medical History:
Per chart:
Onc History
- CLL ([**11/2173**]): Splenectomy, stable plt counts
- [**8-29**]: Progressive anemia; retroperitoneal [**Doctor First Name **] per CT
- [**6-30**]: Increasing WBC
- [**2179-2-15**]: Started chlorambucil
- [**2179-4-27**]: Progressive fatigue
- [**2179-5-4**]: Entostatin/rituxan
- [**2179-7-1**]: 1st cycle PCR
---Pentostatin ([**2179-7-1**])
---Pentostatin/rituxan/cyclophosphamide ([**2179-7-21**])
.
Past Medical History
- HTN
- DM
- PAF on coumadin
- h/o sepsis
- GERD
- BPH s/p TURP in [**9-29**], now with chronic indwelling foley
- h/o HSV I oral lesions
Social History:
.
No smoking, occasional EtOH, not married
Lives alone on [**Location (un) 1773**] in [**Hospital1 **] [**Hospital3 4634**]
Family History:
.
Mother, father: Died of unknown causes
Brother: Died of leukemia
Physical Exam:
VS: 98.1 122/76 102 20 97% RA
GENL: comfortable, NAD, extremely talkative
HEENT: PERRLA, EOMI, Sclerae anicteric, no oral lesions, MMM,
poor dentition, no carotid bruits.
Lungs: Clear to auscultation bilaterally. No rhales, rhonchi or
wheezes.
Heart: regular. 2/6 Systolic murmur loudest at LUSB, no
radiation to carotids.
Abdomen: Soft, non-tender, nondistended, + BS
Extremities: Bilateral +1 pitting edema to ankles BL, with trace
edema to mid shins BL.
Neuro: alert, no gross CN deficits
Skin: excoriations over left shin, small dark scab on top of L
foot
Pertinent Results:
[**2179-8-27**] 11:30AM LD(LDH)-303* CK(CPK)-20* TOT BILI-0.4 DIR
BILI-0.2 INDIR BIL-0.2
[**2179-8-27**] 11:30AM HAPTOGLOB-217*
[**2179-8-27**] 11:30AM WBC-17.1*# RBC-2.51* HGB-7.5* HCT-22.0*
MCV-88 MCH-30.1 MCHC-34.3 RDW-15.0
[**2179-8-27**] 11:30AM NEUTS-6* BANDS-0 LYMPHS-93* MONOS-0 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2179-8-27**] 11:30AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
ELLIPTOCY-OCCASIONAL
[**2179-8-27**] 11:30AM PLT SMR-LOW PLT COUNT-142*# LPLT-3+
[**2179-8-27**] 11:30AM PT-97.4* PTT-62.6* INR(PT)-13.4*
[**2179-8-27**] 11:30AM RET AUT-0.4*
[**2179-8-27**] 03:20PM URINE RBC->50 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-0
[**2179-8-27**] 03:20PM URINE BLOOD-LG NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR
[**2179-8-27**] 03:20PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2179-8-27**] 07:16PM PT-76.7* PTT-51.6* INR(PT)-10.0*
[**2179-8-27**] 07:16PM WBC-17.1* RBC-2.72* HGB-8.6* HCT-24.2* MCV-89
MCH-31.5 MCHC-35.3* RDW-14.7
[**2179-8-27**] 07:16PM PLT COUNT-122* LPLT-2+
[**2179-8-27**] 10:02PM URINE RBC-21* WBC-0 BACTERIA-MANY YEAST-NONE
EPI-0
Brief Hospital Course:
.
Studies:
CXR [**2179-8-27**]: "There is a patchy opacity in the posterior recesses
in the posterior segment of the left lower lobe suspicious for a
pneumonia. The previously noted reticular interstitial opacities
in the left suprahilar and right perihilar regions are again
noted and relatively stable. The remainder of the lungs is
clear. There is atherosclerotic disease of the aorta. The
cardiac silhouette is top normal for size and stable. There is
blunting of bilateral costophrenic angles which may be due to
small underlying effusions.
.
"No suspicious osseous lesions are identified. IMPRESSION: Left
lower lobe pneumonia. Followup radiographs to document
resolution recommended."
.
CHEST CT [**2179-7-25**]:
"IMPRESSION:
"1. New area of consolidation is noted within the left lower
lobe
which in correct clinical setting might represent development of
pneumonia. Follow up after antibiotic treatment is recommended.
"2.The extensive interstitial thickening accompanied by lower
lung predominant ground glass attenuation and scattered small
nodules are unchanged. This appearance is most likely suggestive
of infection.
"3. Extensive lymphadenopathy, in keeping with a history of CLL.
"4. Diffuse coronary artery calcifications.
"5. Evidence of previous asbestos exposure with calcified
pleural
plaques."
.
.
A/P:
76M h/o CLL (dx in [**2165**], s/p splenectomy and chemo, last dose on
[**7-21**]), DM, HTN, BPH s/p TURP and indwelling foley, PAF on
coumadin presented with gross hematuria, INR of 13.4. Admitted
to the ICU for hemodynamic monitoring, hemodynamically stable
overnight, transferred to BMT service for resolution of
coagulopathy and continued monitoring.
.
#) Gross hematuria: Hematuria was only noted in the ED, and by
the time Mr [**Name13 (STitle) **] arrived in the ICU it had cleared. Team
noted that patient had been on fluconazole, ciprofloxacin, and
had also had Foley. Patient received 1U pRBC in the ED his Hct
bumped from 22 to 24. However, his subsequent HCT was 21.3, for
which he received another 1 unit PRBC. Has been hemodynamically
stable since presentation and hematuria resolved.
.
#) Supratherapeutic INR: Initial top of the differential was
drug interaction (given recent antibiotics): the patient had
very high doses of coumadin (19mg/20mg daily alternating)
together with recent cipro and fluconazole treatment initiated
at [**Location (un) 745**]-Wellseley. At [**Hospital1 18**], he received Vitamin K 10mg sc x1
and 2x FFP in the ED. INR came down from 14 to 10 to 7.8. His
hematuria resolved and he has no other signs of bleeding. His
INR on the day of discharge was 2.0.
.
#) Questionable LLL pneumonia on CXR: Pulmonary attending in ICU
felt pneumonia not most likely diagnosis. He has been afebrile
and has had no change in his cough. Given his clinically stable
condition, the radiographic finding might be nonspecific. He was
covered with one dose of CTX and azithro given in the ED. Not
covered in the ICU overnight with no bad effect.
.
#) Chronic indwelling foley: E. coli UTI during last admission
at [**Hospital1 18**] (sensitive to CTX, resistant to Bactrim, Cipro, Gent
and Amp). [**2179-8-6**] from Bactrim to Keflex (250 mg four times a
day) to be taken for 2 weeks; however, patient believed he was
still taking abx on arrival, thought it was Cipro. In the ED, UA
was positive for nitrite and bacteria but no WBC, suggesting
chronic colonization. Patient received CTX x1 in ED for CAP, to
which E. coli was also sensitive. Will not continue chronic
Bactrim ppx for now (although still in OMR listed) given recent
note from Dr. [**First Name (STitle) 1557**]. Urine culture from [**8-28**] needs to be
followed up as outpatient.
.
#) CLL: Dx in [**2165**], s/p splenectomy and chemo; last on [**2179-7-21**]
c/b febrile neutropenia requiring admission. WBC currently 17.1,
ranging 13-36 over the last few weeks. Diffuse LAD on exam.
Continued allopurinol.
.
#) Paroxysmal atrial fibrillation. Coumadin was restarted and he
was sent home with his beta blockade.
.
#) Hypertension. Hemodynamically stable currently with high
normal blood pressure on beta-blocker after transfer from [**Hospital Unit Name 153**].
.
#) Diabetes mellitus. Discharged home with glipizide.
Medications on Admission:
Insulin SC (per Insulin Flowsheet)
Acetaminophen 325-650 mg PO Q6H:PRN
Levothyroxine Sodium 125 mcg PO DAILY
Allopurinol 300 mg PO DAILY
Lidocaine Jelly 2% (Urojet) 1 Appl TP PRN foley 1738
Atenolol 25 mg PO BID
Bisacodyl 10 mg PO/PR DAILY:PRN
Phytonadione 5 mg PO DAILY Duration: 2 Doses
Diazepam 10 mg PO HS PRN
Prochlorperazine 10 mg PO Q6H:PRN
Docusate Sodium (Liquid) 100 mg PO BID
Senna 1 TAB PO BID:PRN
Fluconazole 200 mg PO Q24H
FoLIC Acid 1 mg PO DAILY
Zolpidem Tartrate 5 mg PO HS
Discharge Medications:
1. Coumadin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. Coumadin 1 mg Tablet Sig: Nine (9) Tablet PO at bedtime.
3. Diazepam 5 mg Tablet Sig: Two (2) Tablet PO HS PRN ().
4. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
10. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
11. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
12. Insulin Asp Prt-Insulin Aspart Subcutaneous
13. Outpatient Lab Work
Please check INR weekly; fax results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] ([**Telephone/Fax (1) 51492**]
Discharge Disposition:
Home With Service
Facility:
Care Solutions, Inc
Discharge Diagnosis:
Hematuria secondary to elevated INR
Chronic lymphocytic leukemia
Discharge Condition:
Stable hematocrit, no hematuria, tolerating PO
Discharge Instructions:
You were admitted with blood in your urine and elevated INR.
Please keep your follow up appointment with Dr. [**First Name (STitle) 1557**] tomorrow.
You are being discharged with your standard dose of coumadin
(19mg), but your INR will be followed by your VNA.
.
If you develop fevers, bleeding, chills, nausea, vomiting, or
other concerning symptoms, please seek medical attention
immediately.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 6175**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2179-8-30**] 2:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 22903**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3241**]
Date/Time:[**2179-8-30**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**]
Date/Time:[**2179-9-30**] 3:10
|
[
"42731",
"25000",
"4019",
"53081",
"V5861"
] |
Admission Date: [**2171-6-27**] Discharge Date: [**2171-6-28**]
Date of Birth: [**2118-6-27**] Sex: F
Service: MEDICINE
Allergies:
Haldol / Penicillins / Cephalosporins
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Unresponsive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
53F Schizoaffective disorder, left NH yesterday during PM on
leave, returned around 10PM last night. Seen by NH staff around
2:30AM unresponsive with snoring respirations. Pt brought to
[**Hospital **] hospital at 3:20AM. +posturing, No Sz. T93 ABG 7.36/24/133
P 80 BP 129/65. NH staff found empty Tylenol PM bottles and
suicide note at 6AM. Serum APAP 794 mcg/mL ? from 6:30AM labs or
4AM labs. Took up to 188 Tylenol PM (500mg APAP/25mg
diphenhydramine per tab). PTA, pt intubated, given insulin for
FS 300s, and 9 g N-acetylcysteine.
Past Medical History:
NIDDM
Hypothyroidism
Obesity
Schizoaffective d/o
Social History:
NHR, No known smoking, no ETOH
Family History:
NC
Physical Exam:
Sedated, intubated NGT in place NAD
Skin: pale, dry
HEENT: NC/AT no trauma PERRL 3-->2mm OP moist
Neck: supple
Lungs: CTA No R/R/W
CV: RRR no MRG
Abd: Soft, Decr BS No HSM, NTP, no masses
Ext: No E/C/C
Back: No CVAT
Neuro:oves all 4 ext, withdraws to pain, toes downgoing, no
response to voice, no posturing
Pertinent Results:
[**2171-6-28**] 09:56AM BLOOD WBC-22.8* RBC-4.03* Hgb-13.5 Hct-37.4
MCV-93 MCH-33.6* MCHC-36.2* RDW-12.9 Plt Ct-279
[**2171-6-28**] 03:30AM BLOOD WBC-24.0* RBC-4.67 Hgb-15.0 Hct-42.9
MCV-92 MCH-32.2* MCHC-35.0 RDW-12.9 Plt Ct-300
[**2171-6-27**] 03:40PM BLOOD WBC-18.3* RBC-4.44 Hgb-14.5 Hct-40.7
MCV-92 MCH-32.7* MCHC-35.7* RDW-13.3 Plt Ct-275
[**2171-6-28**] 09:56AM BLOOD Plt Ct-279
[**2171-6-28**] 09:56AM BLOOD PT-15.9* PTT-56.8* INR(PT)-1.7
[**2171-6-28**] 03:30AM BLOOD Plt Ct-300
[**2171-6-28**] 03:30AM BLOOD PT-13.8* PTT-43.8* INR(PT)-1.3
[**2171-6-28**] 12:02AM BLOOD PT-13.9* PTT-41.4* INR(PT)-1.3
[**2171-6-27**] 03:40PM BLOOD Plt Ct-275
[**2171-6-27**] 03:40PM BLOOD PT-13.8* PTT-30.9 INR(PT)-1.3
[**2171-6-28**] 09:56AM BLOOD Glucose-114* UreaN-27* Creat-1.8* Na-146*
K-4.6 Cl-116* HCO3-15* AnGap-20
[**2171-6-27**] 03:40PM BLOOD Glucose-162* UreaN-15 Creat-1.4* Na-131*
K-9.3* Cl-103 HCO3-12* AnGap-25*
[**2171-6-27**] 10:16AM BLOOD Glucose-256* UreaN-16 Creat-1.1 Na-136
K-3.7 Cl-102 HCO3-16* AnGap-22
[**2171-6-28**] 09:56AM BLOOD ALT-139* AST-208* CK(CPK)-6020*
AlkPhos-64 TotBili-0.2
[**2171-6-28**] 03:30AM BLOOD ALT-106* AST-166* AlkPhos-86 TotBili-0.2
[**2171-6-28**] 12:02AM BLOOD ALT-105* AST-167* AlkPhos-89 TotBili-0.4
[**2171-6-27**] 10:16AM BLOOD ALT-74* AST-111* CK(CPK)-5318* AlkPhos-83
Amylase-64 TotBili-0.5
[**2171-6-28**] 09:56AM BLOOD CK-MB-80* MB Indx-1.3 cTropnT-<0.01
[**2171-6-27**] 03:40PM BLOOD CK-MB-138* MB Indx-1.9 cTropnT-<0.01
[**2171-6-27**] 10:16AM BLOOD CK-MB-103* MB Indx-1.9 cTropnT-<0.01
[**2171-6-28**] 09:56AM BLOOD Calcium-6.6* Phos-5.5* Mg-1.9
[**2171-6-28**] 03:30AM BLOOD Albumin-3.9 Mg-2.1
[**2171-6-27**] 03:40PM BLOOD Mg-2.2
[**2171-6-28**] 03:30AM BLOOD Acetone-MODERATE Osmolal-312*
[**2171-6-27**] 03:40PM BLOOD Osmolal-296
[**2171-6-27**] 03:40PM BLOOD TSH-0.30
[**2171-6-28**] 09:56AM BLOOD Cortsol-58.4*
[**2171-6-28**] 09:30AM BLOOD Cortsol-69.6*
[**2171-6-28**] 12:02AM BLOOD HBsAb-NEGATIVE HBcAb-POSITIVE
[**2171-6-27**] 10:16AM BLOOD Phenoba-<1.2*
[**2171-6-28**] 09:56AM BLOOD ASA-48* Acetmnp-73.8*
[**2171-6-28**] 03:30AM BLOOD Acetmnp-124.3*
[**2171-6-27**] 10:16AM BLOOD ASA-11 Ethanol-NEG Acetmnp-552.0*
Bnzodzp-NEG Tricycl-NEG
[**2171-6-28**] 12:02AM BLOOD HCV Ab-NEGATIVE
[**2171-6-28**] 09:59AM BLOOD Type-ART pO2-335* pCO2-34* pH-7.31*
calHCO3-18* Base XS--8
[**2171-6-28**] 02:00AM BLOOD Type-ART Temp-37.8 Rates-[**10-14**] Tidal
V-800 O2-40 pO2-99 pCO2-24* pH-7.33* calHCO3-13* Base XS--11
-ASSIST/CON Intubat-INTUBATED
[**2171-6-27**] 05:46PM BLOOD Type-ART pO2-264* pCO2-28* pH-7.29*
calHCO3-14* Base XS--11
[**2171-6-27**] 10:46AM BLOOD Type-ART Rates-/16 pO2-246* pCO2-24*
pH-7.38 calHCO3-15* Base XS--8 -ASSIST/CON Intubat-INTUBATED
[**2171-6-28**] 09:59AM BLOOD Lactate-2.5* K-4.3
[**2171-6-28**] 02:00AM BLOOD Lactate-3.8*
[**2171-6-27**] 05:46PM BLOOD Lactate-3.1*
[**2171-6-27**] 10:46AM BLOOD Glucose-237* Lactate-5.9* Na-133* K-3.6
Cl-102
[**2171-6-28**] 09:59AM BLOOD Hgb-13.7 calcHCT-41 O2 Sat-98
[**2171-6-28**] 02:00AM BLOOD O2 Sat-97
[**2171-6-28**] 09:59AM BLOOD freeCa-0.92*
[**2171-6-27**] 10:46AM BLOOD freeCa-1.18
Brief Hospital Course:
Pt admitted to ICU. Stable overnight other than 1 episode of
aspiration of charcoal, pt was overbreathing the ventilator
despite propofol drip increased to 100mcg/kg/min. CXR was
negative. She was hypotensive with MAP in the 60s, and given her
high requirement for sedation, she was placed on a Levo drip.
The patient continued to have a high AG acidosis, with an
unknown etiology. In the AM, pt found to be in PEA. Code was
called, and pt could not be resucitated despite administration
of Epinephrine, atropine. Pronounced deceased at 1014AM. ME
notified and accepted case.
Medications on Admission:
Clozaril, Motrin, Percocet, Senna, Colace, Levoxyl
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Overdose of Tylenol
Discharge Condition:
Deceased
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"5070",
"2762"
] |
Admission Date: [**2165-2-8**] Discharge Date: [**2165-2-18**]
Date of Birth: [**2089-4-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Statins-Hmg-Coa Reductase Inhibitors / Morphine / Citalopram /
Thiazides
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Cough, dyspnea on exertion
Major Surgical or Invasive Procedure:
left heart catheterization, coronary angiogram, left
ventriculogram [**2165-2-11**]
coronary artery bypass grafts x4(LIMA-LAD, SVG-dg,
SVG-OM,SVG-PDA) [**2165-2-12**]
History of Present Illness:
This is a 75 year old man with chronic obstructive pulmonary
disease, hypertension and Hepatitis C who presented to the
[**Hospital 882**] Hospital with 4-5 days of increasing cough and
shortness of breath. He has not seen a doctor for a year [**First Name8 (NamePattern2) **]
[**Hospital1 882**] report.
He reported that dysnea is typical for him but that it had been
worse in the last 4-5 days and that his sputum is typical but
had been darker and yellow-green in the last 4-5 days. He
reported that his baseline is to be able to walk 1 block before
getting short of breath..
A CXR showed no clear signs of pneumonia. EKG showed sinus
rhythm at 95,,no ST-T changes.
In the [**Hospital1 882**] ED he was given 2L NS, 500 mg IV levofloxacin;
albuterol; duonebs and 125 mg solumedrol.
He was admitted to the medicine floor for further management. On
the [**Hospital1 882**] medicine floor he had [**8-30**] SSCP on 2 AM of [**2-8**]
which was relieved with nitro x3 and Maalox. He again had [**8-30**]
SSCP which nitrox3 and Maalox only brought down to 3/10. On both
of these occasions, EKG showed [**Street Address(2) 4793**] depressions in V4-6. He
got Heparin 4000 units followed by drip of 1100 units/hr; Plavix
300 mg; and Metoprolol 12.5 mg. A statin allergy was listed in
his chart so a statin was not given. (Pt denied allergies but
was judged to be possibly an unreliable historian.)
He had already received his home Aggrenox at 10 am; Enalapril 10
mg at 10:30 am; and Verapamil 40 mg at 2 pm. Transfer to [**Hospital1 18**]
for cath was arranged. Cardiac surgery evaluated for coronary
artery revascularization.
Past Medical History:
paroxysmal atrial fibrillation
hypertension
chronic obstructive pulmonary disease
Hepatitis C
gastroesophageal reflux
anxiety/depression
s/p herniorraphy
s/p shoulder surgery
Social History:
edentulous
120pack year smoker, stopped 7 years ago
heavy ETOH until 7 years ago
lives in [**Hospital3 **] facility
Family History:
father died of MI in his 60s
Physical Exam:
admission:
Pulse:64 Resp:20 O2 sat: 94%RA
B/P Right:162/76 Left:170/91
Height:5'9" Weight:72.6kg
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur ii?vi sem
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact x
Pulses:
Femoral Right: +1 Left: +1
DP Right: +1 Left: +1
PT [**Name (NI) 167**]: +1 Left: +1
Radial Right: +1 Left: +1
Carotid Bruit Right: 0 Left: 0
Pertinent Results:
[**2165-2-17**] 03:32AM BLOOD WBC-8.1 RBC-3.07* Hgb-9.3* Hct-27.0*
MCV-88 MCH-30.3 MCHC-34.6 RDW-15.0 Plt Ct-149*
[**2165-2-9**] 07:25AM BLOOD WBC-13.4* RBC-4.06* Hgb-12.6* Hct-37.6*
MCV-93 MCH-30.9 MCHC-33.4 RDW-13.8 Plt Ct-184
[**2165-2-12**] 12:41PM BLOOD PT-14.4* PTT-36.9* INR(PT)-1.2*
[**2165-2-9**] 12:25AM BLOOD PT-13.9* PTT-67.2* INR(PT)-1.2*
[**2165-2-17**] 03:32AM BLOOD Glucose-115* UreaN-15 Creat-0.8 Na-136
K-3.4 Cl-98 HCO3-34* AnGap-7*
[**2165-2-9**] 07:25AM BLOOD Glucose-100 UreaN-18 Creat-0.8 Na-144
K-4.2 Cl-107 HCO3-30 AnGap-11
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname 177**] [**Hospital1 18**] [**Numeric Identifier 85808**] (Complete)
Done [**2165-2-12**] at 10:31:10 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Department of Cardiac S
[**Last Name (NamePattern1) 439**], 2A
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2089-4-28**]
Age (years): 75 M Hgt (in): 69
BP (mm Hg): / Wgt (lb): 160
HR (bpm): BSA (m2): 1.88 m2
Indication: Intraop CABG ?AVR. Evaluate valves, wall motion,
aortic contours
ICD-9 Codes: 424.0, 424.1
Test Information
Date/Time: [**2165-2-12**] at 10:31 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW1-: Machine: AW 2
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 4.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.2 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.6 m/s
Left Atrium - Peak Pulm Vein D: 0.3 m/s
Left Atrium - Peak Pulm Vein A: 0.1 m/s < 0.4 m/s
Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.1 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.4 cm
Left Ventricle - Fractional Shortening: *0.17 >= 0.29
Left Ventricle - Ejection Fraction: 45% to 50% >= 55%
Left Ventricle - Stroke Volume: 76 ml/beat
Aorta - Annulus: 2.7 cm <= 3.0 cm
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 3.0 cm <= 3.0 cm
Aorta - Ascending: *4.1 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 2.0 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 17 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 12 mm Hg
Aortic Valve - LVOT pk vel: 0.80 m/sec
Aortic Valve - LVOT VTI: 22
Aortic Valve - LVOT diam: 2.1 cm
Aortic Valve - Valve Area: *1.7 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 0.9 m/sec
Mitral Valve - Mean Gradient: 1 mm Hg
Mitral Valve - Pressure Half Time: 90 ms
Mitral Valve - MVA (P [**12-22**] T): 2.4 cm2
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 1.17
Findings
LEFT VENTRICLE: Normal LV wall thickness and cavity size. Normal
LV cavity size. Mild regional LV systolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Moderately
dilated ascending aorta. Normal aortic arch diameter. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Moderately thickened aortic valve leaflets. Mild
AS (area 1.2-1.9cm2). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. The
MR vena contracta is <0.3cm. Eccentric MR jet. Mild (1+) MR. [**Name13 (STitle) 15110**]
to the eccentric MR jet, its severity may be underestimated
(Coanda effect).
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
No PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre Bypass: Left ventricular wall thicknesses and cavity size
are normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with mild to
moderate anterior hypokinesis. Right ventricular chamber size
and free wall motion are normal. The ascending aorta is
moderately dilated. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets are moderately thickened. There
is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. An eccentric, posteriorly directed jet of Mild (1+)
mitral regurgitation is seen. Due to the eccentric nature of the
regurgitant jet, its severity may be significantly
underestimated (Coanda effect). There is no pericardial
effusion.
Post Bypass: Preserved biventricular function with some interval
improvement in anterior wall motion. LVEF 50%. MR remains mild.
Aortic valve gradients unchanged. Aortic contours intact.
Remaining exam is unchanged. All findings discussed with
surgeons at the time of the exam.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2165-2-13**] 14:53
?????? [**2157**] CareGroup IS. All rights reserved.
Brief Hospital Course:
On [**2165-2-12**] Mr.[**Known lastname **] was taken to the operating room and under
went quadruple vessel bypass (Left internal Mammary artery
grafted to the Left Anterior Descending artery, Saphenous Vein
Grafted to diag, SVG to Obtuse Marginal ,Saphenous Vein Grafted
to Ppsterior Descending Artery).See operative note for details.
He weaned from bypass on Neo Synephrine and Propofol. He awoke
neurologically intact and was extubated on the first morning
after surgery without difficulty. Pressors weaned easily.
Beta-Blockers/Statin/Aspirin/diuresis was initiated. All lines
and drains were discontinued in a timely fashion. He had atrial
fibrillation post operatively which responded to Amiodarone and
converted to sinus rhythm. Mr.[**Known lastname **] remained in the CVICU due to
his tenuous pulmonary status. He remained hemodynamically stable
and required aggressive diuresis and bronchdilators for dyspnea.
Nutrition was consulted to evaluate his swallowing function and
nutritional intake. Social work continued to follow
postoperatively as well. He continued to progress and on POD#5
he was transferred to the step down unit for further monitoring.
Physical therapy was consulted to evaluate strength and
mobility. His respiratory status continued to improve and he was
saturating 93% on room air at the time of discharge. A swallow
evaluation was performed [**2165-2-18**] due to history of dysphagia and
observed regurgiation of thin liquids. It was recommened he
continue a regular diet with thin liquids with a video swallow
follow up as an outpatient. The patient was informed of this
recommendation and instructed to follow up with GI as an
outpatient #[**Telephone/Fax (1) 3731**]. The remainder of his postoperative
course was essentially uneventful. He continued to progress and
on POD#he was cleared by Dr.[**Last Name (STitle) **] for discharge to rehab. All
follow up appointments were advised.
STOPPED [**2-17**]
Medications on Admission:
Enalapril 10mg po daily
Omeprazole 20mg po daily
Fluoxetine 20mg po TID
Vesicare 5mg po daily
Verapamil 120mg po daily
Terazosin 2mg po BID
Reglan 5mg po BID
Aggrenox 1 tab po BID
Trazadone 150mg po qHS
Plavix - last dose:300mg [**2-8**] and 75 daily
Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
2. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
4. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
Disp:*60 Capsule(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*2*
7. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 * Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
9. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
10. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 1 months. Tablet(s)
11. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day
for 1 months.
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain.
14. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for dyspnea.
15. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
17. Vesicare 5 mg Tablet Sig: One (1) Tablet PO daily ().
18. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
19. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
20. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 10
days.
21. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day for 10
days.
22. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
paroxysmal atrial fibrillation
hypertension
chronic obstructive pulmonary disease
Hepatitis C
anxiety/ depression
gastroesophageal reflux disease
s/p repair right shoulder separation
s/p hernia repair
Discharge Condition:
Alert and oriented x 3, nonfocal
ambulating with steady gait
sternal pain managed with Percocet
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Recommended Follow-up:Please call to schedule appointments
Surgeon Dr [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**2165-3-27**] at 1PM
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 250**] on [**2165-4-4**] at
2:15 PM
Cardiologist Dr [**Last Name (STitle) **] in [**12-22**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2165-2-18**]
|
[
"41071",
"486",
"41401",
"42731",
"4019",
"53081",
"2859",
"2875"
] |
Admission Date: [**2189-6-16**] Discharge Date: [**2189-6-18**]
Service: TRA
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
lady status post fall down four flights of stairs. Positive
loss of consciousness. The patient presented to an outside
hospital where she was noted to have a subarachnoid
hemorrhage and subdural hematoma. The patient was therefore
Medflighted to [**Hospital1 69**] for
further care. In the Emergency Room the patient remained
hemodynamically stable. The patient was noted to have a left
wrist deformity as well as ecchymosis over her left eye.
PAST MEDICAL HISTORY: High blood pressure, bilateral knee
replacements.
PAST SURGICAL HISTORY: As above.
MEDICATIONS: Lopressor.
ALLERGIES: Amoxicillin.
PHYSICAL EXAMINATION: Vital signs 101.8, heart rate 67,
blood pressure 144/78, respiratory rate 20, pulse ox of 99
percent on two liters. Left periorbital ecchymosis noted.
HEENT: Pupils equal, round and reactive to light. Tympanic
membranes clear. A 2 cm laceration over the left frontal
area. Cardiovascular: Regular rate and rhythm.
Respiratory: Clear to auscultation bilaterally. Chest: No
deformities or tenderness. Abdomen: Soft, non-tender, non-
distended. Pelvis stable. Flanks within normal limits.
Back: No deformities, no tenderness. Spine: No
deformities, no step-off or tenderness. Rectal: Guaiac
negative, good rectal tone. Right upper extremity and right
lower extremity, left lower extremity: No deformities. Left
upper extremity: Deformity at the left wrist. Pulses:
Palpable pulses throughout. Neurological examination: GCS
15.
LABORATORY: CBC 13.6, 36.4, 261,000. Chem panel: 139, 4.4,
103, bicarb 31, BUN 24, creatinine 0.8, glucose 150. INR
1.0. ____ 1.2. Fibrin 386. Amylase 31.
RADIOLOGY: Fast examination was not done. Chest x-ray was
within normal limits. Pelvis was within normal limits.
Cervical spine at outside hospital was within normal limits.
CT of the head showed a right subdural hematoma,
intraventricular hemorrhage, subarachnoid hemorrhage,
intraorbital air, maxillary sinus fluid. CT of the face
revealed fracture of the left fovea ethmoidalis and left
lamina papyracea. CT of the abdomen was negative. Plain
film of the left wrist revealed a Colles' fracture. Also
noted a fracture of the ulnar styloid. No evidence of intra-
articular extension.
HOSPITAL COURSE: Patient was admitted to the Intensive Care
Unit in stable condition. The patient underwent q. 1h.
neurological checks which revealed no deficits. The patient
underwent a repeat CT of the head on hospital day two which
revealed a stable appearance of the brain and intracranial
hemorrhage. The patient also underwent a closed reduction of
the Colles' fracture in the Operating Room, without any
complications. The patient was transferred to the floor on
hospital day two in stable condition. Vital signs remained
stable and no further medical issues arose during the
remainder of her hospital stay. The patient was evaluated by
Physical Therapy and Occupational Therapy who deemed that
patient would benefit from further physical therapy which
will be provided by VNA services. The patient was discharged
to home in stable condition. The patient was also evaluated
by the Ophthalmology Service for her facial fractures and
obvious trauma to the left eye. The patient was noted to
have elevated intraocular pressure within the 20's and was
treated medically for this. Orbit was intact and there was
no indication of any retinal involvement.
DISCHARGE DIAGNOSES: Left Colles' wrist fracture.
Right subdural hematoma/subarachnoid hemorrhage.
Intraventricular hemorrhage.
Right temporal lobe contusion.
Left orbital and left frontal fractures.
Left ocular pressure elevation.
DISCHARGE MEDICATIONS:
1. Phenytoin 100 mg p.o. t.i.d. times five days.
2. Percocet one to two tablets p.o. q. 4-6h. p.r.n. pain.
3. Metoprolol 37.5 p.o. b.i.d.
4. Colace 100 mg p.o. b.i.d.
5. Dorzolamide/timolol drops, one drop ophthalmic b.i.d. to
left eye.
FOLLOW UP: The patient declined to follow up back in [**Location (un) 86**]
as she is from [**Location (un) 3320**]. Therefore, arrangements were made
with her orthopedic surgeon at [**Location (un) 3320**] who agreed to follow
up for her Colles' fracture. Arrangements were also made for
the patient to follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Location (un) 3320**] for
Neurosurgery and follow up CT. The patient will also follow
up with her ophthalmologist on Monday. Discharge
instructions were explained to patient and family who
expressed understanding. The patient will also follow up
with her primary care physician [**Name Initial (PRE) 503**]. PCP is aware of
plan. The patient was also discharged with copies of films
and radiology reports.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13137**]
Dictated By:[**Last Name (NamePattern1) 27758**]
MEDQUIST36
D: [**2189-6-18**] 16:51:37
T: [**2189-6-18**] 17:30:02
Job#: [**Job Number 56179**]
|
[
"5990",
"4019"
] |
Admission Date: [**2135-12-16**] Discharge Date: [**2135-12-22**]
Date of Birth: [**2087-9-2**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
N/V
Major Surgical or Invasive Procedure:
[**2135-12-16**]: right parietal craniotomy and resection of tumor
History of Present Illness:
48M with a hx of renal cell carcinoma and currently on Sutent.
He reports nausea/vomiting since Thursday [**12-8**], he spoke to his
oncologist who prescribed an antiemetic but recommended he go to
the ER for IVF if the nausea continued. He presented to the OSH
ER on [**12-10**] where a head CT showed a R ICH that is concerning
for a underlying mass. He was admitted and underwent a work up
for this lesion. He was cleared for discharge home and returns
on [**12-16**] electively for resection of this lesion.
Past Medical History:
- RCC with mets to R lung and heart
- Back surgery to L5-S1 in [**2124**], with no hardware, done at
[**Hospital 5279**]
Hospital in [**Location (un) 5450**]
- Tonsillitis as a child
- History of pneumonia as a child
- History of cholecystectomy in [**2133**]
- History of questionable bronchitis in [**12/2133**] and [**1-/2134**],
which may have reflected actual disease recurrence
- Depression
- GERD
Social History:
Lives with his partner. [**Name (NI) **] worked as a mortgage banker and has
been unemployed and on disability since [**2134-9-20**]. Denies
tobacco, reports social use of ETOH. Denies recreational drug
use. Was previous smoker x 20 + years
Family History:
- Mother: RA, DM, hypothyroidism
- Father: Unknown to patient
- Daughter: Hodgkin's lymphoma age 19
Physical Exam:
Gen: WD/WN, comfortable, NAD.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 3 mm
bilaterally. Visual fields - left field cut.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-16**] throughout. Left pronator drift
Sensation: Intact to light touch
Coordination: L dysmetria on finger-nose-finger
Skin: scalp incisional wound CDI
Pertinent Results:
[**12-16**] ECHO:
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%). There is a mass or tumor in the
right ventricle which fills the apex and extends well into the
RV cavity. The mass measures 4.7 cm x 6.9 cm in mid-esophageal
long axis view. The mass is seen extending into the RVOT 1-2 cm
from the pulmonic valve, however no turbulent flow is seen in
the RVOT by color flow doppler. The mean gradient is 1 mmHg at a
blood pressure of 95/54. The right ventricular free wall
thickness is normal. The right ventricular cavity is markedly
dilated with focal hypokinesis of the apical free wall. The
portion of right ventricular free wall that is unaffected by
tumor appears to contract normally. There is abnormal diastolic
septal motion/position consistent with right ventricular volume
overload.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. Mild to
moderate ([**2-13**]+) tricuspid regurgitation is seen.
[**12-16**] [**Month/Day (4) 4338**] Brain:
IMPRESSION:
1. Short-term stability of extensive hemorrhagic mass in the
right parietal lobe with additional smaller lesions in the left
frontal and parietal lobes.
2. No evidence of new lesions. No new mass effect or hemorrhage.
[**12-16**] CT Head:
IMPRESSION: Postoperative changes from resection of right
parietal mass.
[**12-17**] [**Month/Day (1) 4338**] brain:
IMPRESSION: 1. Status post right parietal craniotomy with
expected post-surgical changes and blood products in the
surgical bed; with gadolinium contrast, no frank evidence of
residual mass lesion is identified; however, close followup is
recommended.
2. No diffusion abnormalities are detected to suggest acute or
subacute
ischemic changes. Persistent vasogenic edema and asymmetry of
the right
ventricular trigone and right temporal ventricular [**Doctor Last Name 534**]. There
is no evidence of new areas with abnormal enhancement.
Brief Hospital Course:
Patient electively presented and underwent craniotomy and
resection of mass. Surgery was without complication. Please see
the operative report for details. He was extubated and
transferred to the ICU. Post operatively he had persistent left
field cut/ slight left pronator drift but was otherwise
neurologically well. He had persistent N/V therefore multiple
anti-emetics were ordered. Head CT was stable post op, with no
hemorrhage. He was continued on IVF with a goal of euvolemia.
The following day his nausea continued. IVF's and decadron 4mg
q6h were continued. He underwent an [**Doctor Last Name 4338**] for post op evaluation
which revealed post operative changes.
He was kept in the ICU for close observation and euvolemia
maintenance. He was transferred to the floor. During his
decadron taper his left sided drift/weakness slightly worsened.
His decadron was increased again.
He was seen by PT and OT and they recommend dicharge extended
care facility with PT/OT services.
Medications on Admission:
1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO QHS (once a day
(at bedtime)).
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*30 Tablet(s)* Refills:*0*
4. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*1*
5. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily) as needed for shortness of
breath or wheezing.
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB.
7. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 4-6 hours as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*1*
8. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Medications:
1. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q 8hrs ()
for 99 days: 4q8 on [**12-21**]
3q8 on [**12-22**]
2q8 on [**12-23**]
2 [**Hospital1 **] thereafter.
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB.
3. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
4. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**2-13**]
Tablets PO Q6H (every 6 hours) as needed for headache/.
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
9. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for neck pain.
10. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
11. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Right Parietal lesion
Cerebral edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
General Instructions/Information
YOU [**Month (only) **] RESTART YOUR COUMADIN 2 WEEKS FROM YOUR DATE OF SURGERY
/ YOUR START DATE WILL BE [**2135-12-30**]
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair after 3 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? If you are being discharged on steroid medication, make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation. Make sure to take your steroid medication with
meals, or a glass of milk.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer upon
discharge.
Followup Instructions:
Follow-Up Appointment Instructions
**** you have an appointment in the Brain [**Hospital 341**] Clinic on
[**2136-1-2**] at 3pm
**** YOU WILL NEED TO COME IN EARLIER THAT SAME DAY FOR AN [**Year (4 digits) 4338**] -
YOU SHOULD COME TO THE DEPARTMENT OF RADIOLOGY [**Year (4 digits) 4338**]
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2136-1-2**] 1:15 / THIS IS ALSO ON THE
[**Hospital Ward Name **]
********** The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number
is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
Completed by:[**2135-12-21**]
|
[
"53081",
"311",
"V5861"
] |
Admission Date: [**2186-2-8**] Discharge Date: [**2186-2-17**]
Date of Birth: [**2124-9-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Fever, Altered Mental Status
Major Surgical or Invasive Procedure:
PEG tube
History of Present Illness:
61 y/o man with history of etoh abuse, dementia, DM, CAD, CHF,
living in extended care presenting with reports of fever, cough,
and lethargy x several days. Per reports, has had decreased
verbalization. Was febrile on AM of admission and labs drawn @
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] were notable for WBC 2.7, K+ 5.4.
.
In ED: was febrile to 101.2 and received Vanc/Levo/Flagyl/CTX.
CXR withoutu infiltrate or effusion. Blood/urine cultures sent
and LP performed with 1WBC, 1RBC. EKG with J-point elevation and
first set CE negative. LFTs within normal limits. CT head with
stable old frontal encephalomalacia, generalized atrophy, and
stigmata of chronic ischemic changes. During ER work-up patient
missed many of his daily medications and became markedly
hypertensive to 230s systolic. Multiple medications were given
including hydral 10mg IV x 1, 60mg po x 1, isosorbide 40mg po x
1, lopressor 5mg IV x 2, and lopressor 150mg po x 1 and he was
ultimately placed on labetalol gtt and transfered to the unit.
Past Medical History:
# Alcohol Abuse
# Cirrhosis
# Dementia
# CAD - Cardiac Cath [**Hospital2 **] [**Hospital3 6783**] Hosp [**2184**] w/3VD
# CHF - echo @ [**Hospital1 18**] [**2184**] w/EF 20-25% with both systolic and
diastolic dysfunction
# Right Hip Fracture s/p ORIF [**2184**] @ [**Hospital1 18**]
# PEG [**2184**] @ [**Hospital1 18**] [**2-25**] fialed s/s, pt self d/c'd [**9-/2186**]
# Chronic renal insufficiency (Cr ~ 1.9 at outside facility)
# Diabetes, on Insulin
# Hepatitis C
# Hypertension
# Seizure disorder, on dilantin
# Prior cocaine abuse
Social History:
Current resident @ [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing Home in [**Location (un) **].
further history per previous notes such as prior etoh and
substance abuse.
Family History:
Noncontributory
Physical Exam:
98.8 109 193/112 97% on 2LNC
Gen: somnolent, opens eyes slowly, but does not follow other
comands. Sat up when foley placed and asked "what are you doing"
HEENT: Poor Dentition, moist mucus membranes
NECK: Supple, trachea midline. Jugular vein not prominent
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: coarse breath sounds bilaterally, hoarse gurggling in
upper airway.
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO EXAM: does not follow commands. Pupils are dilated but
equal bilaterally. No increased tone and moves all extremities
spontaneously.
Pertinent Results:
[**2186-2-8**] 09:45AM PT-13.3 PTT-31.3 INR(PT)-1.1
[**2186-2-8**] 09:45AM PLT COUNT-142*
[**2186-2-8**] 09:45AM NEUTS-75.1* LYMPHS-17.8* MONOS-4.9 EOS-1.6
BASOS-0.5
[**2186-2-8**] 09:45AM WBC-5.8 RBC-4.02*# HGB-12.3*# HCT-38.0*#
MCV-95# MCH-30.7 MCHC-32.5# RDW-12.9
[**2186-2-8**] 09:45AM CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-2.0
[**2186-2-8**] 09:45AM CK-MB-3
[**2186-2-8**] 09:45AM cTropnT-0.04*
[**2186-2-8**] 09:45AM CK(CPK)-161
[**2186-2-8**] 09:45AM estGFR-Using this
[**2186-2-8**] 09:45AM GLUCOSE-115* UREA N-31* CREAT-1.8* SODIUM-138
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-24 ANION GAP-11
[**2186-2-8**] 09:49AM LACTATE-1.0
[**2186-2-8**] 12:25PM URINE WBCCLUMP-RARE
[**2186-2-8**] 12:25PM URINE RBC-21-50* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2186-2-8**] 12:25PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-8* PH-7.0
LEUK-NEG
[**2186-2-8**] 12:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2186-2-8**] 07:20PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1*
POLYS-10 LYMPHS-72 MONOS-18
[**2186-2-8**] 07:20PM CEREBROSPINAL FLUID (CSF) PROTEIN-68*
GLUCOSE-74
[**2186-2-8**] 08:15PM PLT COUNT-105*
[**2186-2-8**] 08:15PM NEUTS-84.1* LYMPHS-11.3* MONOS-3.9 EOS-0.6
BASOS-0.2
[**2186-2-8**] 08:15PM WBC-7.1 RBC-3.94* HGB-12.5* HCT-37.5* MCV-95
MCH-31.6 MCHC-33.2 RDW-12.8
[**2186-2-8**] 08:15PM NEUTS-84.1* LYMPHS-11.3* MONOS-3.9 EOS-0.6
BASOS-0.2
[**2186-2-8**] 08:15PM WBC-7.1 RBC-3.94* HGB-12.5* HCT-37.5* MCV-95
MCH-31.6 MCHC-33.2 RDW-12.8
[**2186-2-8**] 08:15PM AMMONIA-<6
[**2186-2-8**] 08:15PM CALCIUM-8.5 PHOSPHATE-3.4 MAGNESIUM-1.7
[**2186-2-8**] 08:15PM CK-MB-4
[**2186-2-8**] 08:15PM cTropnT-<0.01 proBNP-[**2157**]*
[**2186-2-8**] 08:15PM LIPASE-37
[**2186-2-8**] 08:15PM ALT(SGPT)-21 AST(SGOT)-26 CK(CPK)-151 ALK
PHOS-73 TOT BILI-0.6
[**2186-2-8**] 08:15PM GLUCOSE-174* UREA N-29* CREAT-1.6* SODIUM-140
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16
.
AT DISCHARGE
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2186-2-17**] 06:44AM 4.1 3.25* 10.3* 30.2* 93 31.5 34.0 12.4
111*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2186-2-9**] 02:40AM 61 19* 8* 9 0 0 3* 0 0
[**2186-2-9**] 02:40AM 82.4* 0 12.0* 4.7 0.3 0.6
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2186-2-9**] 02:40AM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2186-2-17**] 06:44AM 111*
[**2186-2-17**] 06:44AM 13.11 40.8* 1.1
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2186-2-17**] 06:44AM 132* 15 1.2 135 3.7 107 21* 11
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2186-2-15**] 09:50AM Using this1
DIL,PEP ADDED 12:15PM
1 Using this patient's age, gender, and serum creatinine value
of 1.3,
Estimated GFR = 56 if non African-American (mL/min/1.73 m2)
Estimated GFR = 68 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 60-69 is 85 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2186-2-17**] 06:44AM 13 20
.
[**2186-2-8**] KUB: No evidence of obstruction or free air.
..
[**2186-2-8**] CXR: No evidence of pneumonia.
.
[**2186-2-9**] CXR: Worsening opacification at the bases which may
represent atelectasis or new early pneumonia, as well as small
effusions. Recommend close attention on followup radiographs.
.
[**2186-2-10**] CXR: In comparison with the study of [**2-9**], the right
base is somewhat clearer than on the previous study and the
minimal opacification above it most likely represents merely
atelectatic change. Opacification at the left base in the
retrocardiac region is again seen consistent with atelectasis.
Probable left pleural effusion as well. The upper lung zones are
within normal limits.
.
[**2186-2-14**] RENAL ULTRASOUND
.
61 year old man with Hypertensive Urgency. Please evaluate for
renal artery stenosis
REASON FOR THIS EXAMINATION:
Renal artery stenosis
HISTORY: 61-year-old male with hypertensive urgency, concern for
renal artery stenosis.
RENAL ULTRASOUND WITH DOPPLER: Grayscale, color, and pulse
Doppler son[**Name (NI) 1417**] of both kidneys were performed. Both kidneys
are normal in grayscale appearance, with the right kidney
measuring 10.8 cm and the left kidney 11.1 cm. There is no
evidence of hydronephrosis, stones, or solid renal mass. Doppler
evaluation demonstrates patency of the bilateral main renal
arteries and veins. There are appropriate waveforms
demonstrated. Intrarenal resistive indices of the right kidney
range from 0.66 to 0.71 and on the left from 0.70 to 0.73.
IMPRESSION: Unremarkable renal ultrasound. Patent renal
vasculature. No definite evidence of renal artery stenosis.
.
[**2186-2-9**] CT ABDOMEN AND PELVIS
.
CT ABDOMEN: Visualized lung bases show patchy areas of dependent
airspace opacity that is heterogeneous. There are a few areas of
bronchiectasis in the lower lobes. There is no pleural or
pericardial effusion. Cardiomegaly is unchanged.
Absence of intravenous contrast limits evaluation of the
abdominal parenchymal organs and vasculature. Liver is nodular
and shrunken, unchanged from prior exam, and consistent with
history of cirrhosis. No focal intrahepatic mass or biliary
ductal dilatation. There is no ascites. Gallbladder, pancreas,
spleen, adrenal glands, kidneys, stomach and intra-abdominal
loops of bowel demonstrate normal non-contrast appearance. There
is no free air or free intraperitoneal fluid. There is no
abnormal intra-abdominal lymphadenopathy.
CT PELVIS: Foley catheter balloon is in place within a
decompressed bladder. Pelvic loops of large and small bowel are
unremarkable. There is no free pelvic fluid or abnormal pelvic
or inguinal lymphadenopathy.
There is moderate atherosclerotic calcification of the abdominal
aorta and its branches, without focal dilatation.
OSSEOUS STRUCTURES: Old right femoral fracture fixed with
dynamic hip screw is unchanged. Old fractures of the left
inferior pubic ramus and left pubic symphysis also unchanged.
Compression deformity of the superior endplate of L3 is
unchanged.
IMPRESSION:
1. No acute process in the abdomen or pelvis.
2. Bilateral lower lobe airspace opacities raise concern for
recent aspiration or pneumonia superimposed on chronic lung
disease with areas of bronchiectasis.
3. Unchanged cirrhotic liver.
.
CT HEAD WO CONTRAST [**2186-2-8**]
.
CT HEAD WITHOUT INTRAVENOUS CONTRAST: There is an unchanged area
of cystic encephalomalacia within the left frontal lobe. There
is stable prominence of the ventricles and sulci consistent with
atrophic change. Periventricular and subcortical white matter
hypodensity presumably represents chronic microvascular ischemic
change. There is no evidence for major or minor vascular
territorial infarct, acute hemorrhage, shift of normally midline
structures or hydrocephalus. No fractures are identified. There
is opacification of several anterior ethmoid air cells and mild
thickening within the frontal sinuses. The visualized mastoid
air cells and middle ear cavities are normally pneumatized and
aerated. Again seen is a 13 x 5 mm lipoma along the paramedian
right occipital subcutaneous tissues.
IMPRESSION:
1. No intracranial hemorrhage or mass effect. Stable area of
encephalomalacia in the left frontal lobe which may represent
sequela of old trauma or infarct.
2. Stable moderate atrophy and chronic changes of microvascular
ischemia.
MRI is more sensitive than CT for detection of acute ischemia.
Brief Hospital Course:
Mr. [**Known lastname 1169**] is a 61 y/o man with a history of DM, Etoh abuse,
Dementia, CAD, CHF who presented with fever, altered mental
status, and hypertension.
.
# Fever/Altered Mental status: Considered due to hypertensive
encephalopathy as well as sedation from several psychotropic
drugs. All cultures were negative including influenza DFA. Hie
mental status cleared progressively back to baseline. He
benefited from stopping Ativan and starting 50 mg Provigil
daily.
.
# Hypertension: Initially it was very poorly controlled, >200s,
requiring labetalol/nitro gtt, then transitioned to nitro paste.
He converted to topical and oral medications within 48 hours. He
persistently had somewhat elevated BP and his regimen slowly
adjusted. His ACE inhibitor has been increased, currently at 20
mg/day with improved control, this might be increased further if
necessary. Renal US negative for renal artery stenosis. He will
need to have his BP monitored and medications adjuested if
necessary.
.
# Nausea/vomiting: LFTs within normal limits. Given antiemetics
and the symptoms resolved. Hepatitis serologies have been sent,
results pending at time of discharge.
.
# Chronic Systolic and Diastolic Heart Failure: He had increased
frothy secretions initially, but CXR was without evidence of
pulmonary edema. He has a jugular vein that moves with pulse,
but is not particularly distended. He is euvolemic. He required
no diuresis. These might have been oral secretions in view of
his dysphagia. Secretions resolved prior to discharge. He will
require comfort mouth care.
.
# Chronic Renal Failure with Proteinuria: Chronic hypertensive
disease and diabetic nephropathy, with some component of
prerenal azotemia that responded to gentle hydration
.
# Cirrhosis: Secondary to etoh abuse and hepatitis C. No
coagulopathy or stigmata of decompensation. LFTs remained
normal. Some hepatitis serologies pending as stated above.
.
# History of Seizure Disorder: Unkown details, note made in med
book from [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] that keppra is discontinued, or held for
now. He came on dilantin but his level was 0.6. He was loaded
with one gram and subsequently placed on his regimen of 100 mg
TID. He will need a level drawn within 2-3 weeks.
.
DNR DNI
Medications on Admission:
Metoprolol 150mg po BID
Hydralazine 60mg po Q6Hours
Terazosin 2mg po Qday
Isosorbide 40mg po TID
Remeron 15mg po Qhs
Donepezil 10mg po QHS
Trazadone 25mg po BID
Lorazepam 0.5mg po Qday @ 7am
Lorazepam 0.5mg po Q4h prn anxiety/agitation
Glargine 10 Units po Qday
Regular Insulin Sliding Scale [**Hospital1 **] 4-10 units
Ranitidine 150mg po BID
Albuterol 2puffs po BID prn
Keppra 500mg po Qday (but note made to hold)
Immodium prn
Senna
Dulcolax prn
Milk of Magnesia prn
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
[**1-25**] inh Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
4. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
10. Hydralazine 50 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Modafinil 100 mg Tablet Sig: 0.5 Tablet PO daily am ().
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): For
one month. Then switch to one tablet 40 mg daily.
16. Phenytoin 100 mg/4 mL Suspension Sig: Four (4) mL PO TID (3
times a day).
17. Insulin sliding scale if needed (attached)
usually [**Hospital1 **] 4-10 units
18. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Zofran 4 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
20. glargine Sig: Ten (10) units once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) 2716**] House - [**Hospital1 1559**]
Discharge Diagnosis:
Hypertensive urgency
Dementia
Fever
Discharge Condition:
Good. Tolerating tube feeds. Pain free. Baseline mental status
Discharge Instructions:
Admitted with hypertensive urgency with mental status changes.
This has been getting under control with medication.
.
A PEG tube was started for nutrition, goal 60 cc/hour.
Tolerating well.
.
Started on provigil for alertness and depression.
.
Please adhere to medication regimen and f/u with doctors as
written below.
Followup Instructions:
With Dr [**Last Name (STitle) 5762**] within 1-2 weeks of discharge. Phone nr [**Telephone/Fax (1) 40619**]
Please call a GI doctor if any issues with PEG , phone nr [**Numeric Identifier 68258**]
|
[
"5849",
"5859",
"4280",
"40390",
"V5867"
] |
Admission Date: [**2150-11-16**] Discharge Date: [**2150-12-8**]
Date of Birth: [**2111-12-21**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p Bicycle crash
Major Surgical or Invasive Procedure:
[**2150-11-24**]
1. ORIF Mandible fracture
2. Percutaneous tracheostomy.
[**2150-12-2**]
1. Open reduction internal fixation of bilateral
nasoorbitoethmoid fracture.
2. Open reduction internal fixation of bilateral orbital
rim fracture.
3. Open reduction internal fixation of bilateral maxillary
fracture.
4. Open reduction, internal fixation of bilateral
dentoalveolar fracture and LeFort I fracture.
[**2150-12-2**]
1. Closed reduction and cast application right hand.
2. Close reduction and pin fixation left thumb.
3. Application thumb spica cast left.
[**2150-12-8**]
1. Removal of tracheosotmy
History of Present Illness:
37M non-helmeted bicyclist hit by car. Multiple facial injuries,
intubated on scene to protect airway. Transported to [**Hospital1 18**] for
further care.
Past Medical History:
PMH:none
PSH:foot pinning approx 9 yrs ago after being hit by bus on bike
Family History:
Noncontributory
Physical Exam:
Upon admission:
BP:166 / 88 HR: 68 R on ventilator
O2Sats 100 intubated
Gen: severely disfiguired face due to trauma and actively oozing
blood from facial wounds.
HEENT: Pupils: left [**5-8**] , Right [**4-6**] sluggish reactive.
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neurologic examination:
Mental status: Intubated, sedated.
Cranial Nerves:
Pupils left [**5-8**] , Right [**4-6**] BL sluggishly reactive. No other
obvious facial asymmetry noted
Motor:
normal tone, actively moving all limbs and withdraws to pain as
well.
Reflexes: B T Br Pa Ac
Right 1 1 1 1 1
Left 1 1 1 1 1
Toes mute bilaterally
Coordiantion and gait- not obtainable
Pertinent Results:
[**2150-11-16**] 09:04PM GLUCOSE-139* LACTATE-3.0* NA+-141 K+-4.3
CL--100 TCO2-25
[**2150-11-16**] 08:50PM UREA N-12 CREAT-0.8
[**2150-11-16**] 08:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2150-11-16**] 08:50PM WBC-16.9* RBC-5.14 HGB-17.1 HCT-51.2 MCV-100*
MCH-33.3* MCHC-33.4 RDW-13.0
[**2150-11-16**] 08:50PM PLT COUNT-285
[**2150-11-16**] 08:50PM PT-13.0 PTT-23.8 INR(PT)-1.1
[**2150-11-16**] 08:50PM FIBRINOGE-259
[**2150-11-16**] 11:10PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
Micro/Imaging:
[**2150-12-3**] CT maxill satisfactory alignment
[**2150-12-3**] CXR Lungs clear OGT & R IJ cath out
[**2150-12-3**] CT face good post-surgical alignment.
[**2150-11-30**] cath tip STAPHYLOCOCCUS, COAGULASE NEGATIVE >15
colonies
[**2150-11-26**] R Hand improved subluxation of the first metacarpal. no
fx
[**2150-11-24**] CXR trach in place, no pneumo.
[**2150-11-18**] CXR NG tube with side port superior to GE jxn. need to
adv 8cm
[**2150-11-17**] Head CT small, unchanged R frontal SDH
[**2150-11-17**] CT Max. fx through L optic canal.,mult facial fx.
[**2150-11-17**] Head CT Slight enlargement of two R frontal extra-axial
fluid [**Last Name (un) **]
[**2150-11-17**] Head CT small amount of left frontal SAH
[**2150-11-17**] MRSA screen negative
[**2150-11-16**] R Hand oblique fx through the second and third
metacarpals
[**2150-11-16**] CT C-spine No acute fracture. C5-6, C6-7 degenerative
changes
Brief Hospital Course:
He was admitted to the Trauma Service. Neurosurgery, [**Month/Day/Year **]
Maxillofacial, Plastics, and Ophthalmology were all consulted
due to his injuries. He was admitted to the trauma ICU where he
remained vented and sedated for approximately a week. His
subdural hemorrhage was managed nonoperative and serial
hematocrits remained stable. No further neurosurgical
intervention was being recommended.
Because of his multiple facial injuries and difficulty weaning
from ventilator he was taken to the operating room on [**11-24**] for
tracheostomy. On that same day he underwent stabilization and
fixation of his mandible fracture. There were no intra-operative
complications. He would eventually be weaned off of the
ventilator.
He was evaluated by Plastics for his multiple facial fractures
and metacarpal fractures of right 1st and 2nd digits and of left
1st digit. On [**12-2**] he was taken to the operating room for
definitive repair of his these injures. He was placed in a cast
on the right hand and a thumb spica cast left.
He was noted with ptosis of the left eye and was evaluated by
Ophthalmology; it was felt that this was likely a traumatic
neuropathy. Eye drops were prescribed and he will follow up as
an outpatient in [**Hospital 8183**] clinic.
Cognitive neurology was also consulted given his significant
head injuries and he was recommended for ongoing follow up as an
outpatient. His instructions at time of discharge were very
explicit as recommended by Cognitive Neurology.
Speech and Swallow evaluated him for an [**Hospital 243**] diet for which he
was able to eventually tolerate without any difficulties. His
tracheostomy was downsized and eventually removed prior to his
discharge.
Physical and Occupational therapy were all consulted and worked
with him regularly in preparation for his return to home as he
was unable to go to a rehab facility due to lack of insurance.
He was provided instruction and follow up information for all of
the appointments he need to keep after discharge. He was
discharged to home with friends.
Medications on Admission:
None per patient's mother
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
Disp:*900 ML(s)* Refills:*2*
2. Colace 50 mg/5 mL Liquid Sig: Ten (10) ML's PO twice a day as
needed for constipation.
3. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-6**]
Drops Ophthalmic Q6H (every 6 hours).
Disp:*1 bottle* Refills:*2*
5. Bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic
TID (3 times a day).
Disp:*45 Grams* Refills:*2*
6. Roxicet 5-325 mg/5 mL Solution Sig: [**6-14**] ML's PO every four
(4) hours as needed for pain.
Disp:*600 ML's* Refills:*0*
7. Pepcid 20 mg Tablet Sig: Two (2) Tablet PO twice a day: crush
and dissolve in 30 cc's liquid before taking.
Disp:*120 Tablet(s)* Refills:*2*
8. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Application Ophthalmic twice a day: Apply to left eye.
Disp:*1 tube* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Bicycle crash vs. auto
Small right frontal subdural hematoma
Panfacial fractures
Bilateral zigomatic fratures
Mandibular fracture
Nasal bone/septal fractures
Multiple dental fractures
1st and 2nd right metacarpal fractures
1st left metacarpal fracture
Discharge Condition:
Hemodynamically stable, tolerating an [**Month/Year (2) 243**] diet, pain adequately
controlled, ambulating independently.
Discharge Instructions:
IT IS IMPORTANT THAT YOU WEAR PROTECTIVE HEAD GEAR IF YOU ARE
GOING TO RIDE A BICYCLE/MOTORCYCLE/MOPED.
You were admitted to the hospital following a bicycle crash
where you sustained a small hemorrhage on your brain, this did
not require any operation. Repeat head CT scans were taken and
were stable. You are being recommended to follow up with Dr.
[**First Name (STitle) **] in Cognitive Neurology in a few weeks given your
history of head traumas. You also sustained multiple fractures
of your face and jaw and these were repaired surgically. The
fractures of your fingers on both hands required casting and you
will follow up with the Hand specialist as outlined in your
follow up appointment section.
Your jaws were wired shut during the operation to rpeair the jaw
fracture. You have been given wire cuters to use in the event
that you become short of breath, have nausea with vomiting; you
will need to cut the wires on both sides to release them and
return to the Emergency room immediatley. You also need to
continue to use the Peridex mouthwash four times per day.
Apply the eye ointment to your left eye in the morning and at
night. Apply Bacitracin ointment to your facial wounds three
times/day. Be sure you use the Bacitracin meant for eyes only.
Return to the Emergency room if you develop any fevers, chills,
increased redness/draiange for many of your incicisions,
increased jaw pain, shortness of breath, chest pain, nausea,
vomiting, diarrhea and/or any other symptoms that are concerning
to you.
Keep the area on the front of your neck where your tracheostomy
was removed covered with a dry gauze. This should be changed
daily. The opening will close in about 1-2 weeks.
Adhere to foods that are soft that do not require any chewing.
Drink Carnation instant breakfast at least 3x/day to supplement
your diet and to promote healing of your fractures and other
injuries.
You have many appointments for follow up; please be sure to keep
these appointments as instructed. The numbers have been provided
in the event that you need to change the times/dates.
Followup Instructions:
You have appointments with the following:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7304**], MD Ophthamology Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2150-12-11**] 10:30
Provider: [**Name10 (NameIs) **] MAXILLOFACIAL [**Doctor First Name 147**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2150-12-11**] 1:00
Provider: [**Name10 (NameIs) **] SURGERY CLINIC with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Phone:[**Telephone/Fax (1) 4652**] Date/Time:[**2150-12-11**] 2:30
Follow up with Dr. [**Last Name (STitle) **], Trauma surgery in 2 weeks. Call
[**Telephone/Fax (1) 6429**] for an appointment.
Follow up in [**4-8**] weeks with Dr. [**Last Name (STitle) 84621**], Cognitive Neurology.
Call [**Telephone/Fax (1) 1690**] for an appointment.
Follow up with Dr. [**First Name (STitle) **], Neurosurgery in 4 weeks. You will
need to have a repeat head CT scan for this appointment. Call
[**Telephone/Fax (1) 1669**] for an appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2151-3-3**]
|
[
"51881"
] |
Admission Date: [**2163-6-7**] Discharge Date: [**2163-6-17**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
Dehydration.
Major Surgical or Invasive Procedure:
PICC line placement x 2
EGD
History of Present Illness:
Briefly, pt is a [**Age over 90 **] y/o F w/hv PVD, ruptured AAA s/p repair
[**10-9**], who presented from [**Hospital 100**] Rehab on [**2163-6-7**] for decreased po
intake. Pt was recently hospitalized from [**Date range (1) 31136**] for
pneumonia and was treated with a course of levofloxacin. Per
report from [**Hospital 100**] Rehab, she then developed oral thrush and
refused to eat or drink, although she denied pain with eating
and drinking. The pt's son visited her at the nursing home and
felt she did not appear as alert as her baseline. Due to concern
for dehydration, she was admitted to the [**Hospital Ward Name **].
Past Medical History:
1. Ruptured abdominal aortic aneurysm repaired in [**Month (only) **]
of [**2158**].
2. Depression.
3. Peripheral vascular disease.
4. Degenerative joint disease.
5. Hypertension.
6. Status post total abdominal hysterectomy.
7. CAD s/p mi managed medically.
Social History:
The patient does not drink. Does not smoke.
Is a retired attorney and retired teacher. Is a widow and
has one son.
Currently living at an [**Hospital3 **] facility.
She ambulates with assistance.
Family History:
non-contributory
Physical Exam:
T=98, 140/60 HR 68, RR=18, O2=95% RA
sleeping, in NAD
neck supple, no JVD, no nodes
dry MM, opaque yellow discharge in post pharnx
RRR nml S1S2, no mrg
Abd soft, NT, ND, naBS
Ext no cce, ecchymoses on b/l LE
Pertinent Results:
[**2163-6-7**] 02:02AM WBC-15.1*# RBC-4.50 HGB-14.3 HCT-42.9# MCV-95
MCH-31.8 MCHC-33.3 RDW-15.0
[**2163-6-7**] 02:02AM NEUTS-80* BANDS-2 LYMPHS-10* MONOS-6 EOS-0
BASOS-0 ATYPS-2* METAS-0 MYELOS-0 NUC RBCS-1*
[**2163-6-7**] 02:02AM PLT SMR-NORMAL PLT COUNT-195
[**2163-6-7**] 02:02AM PT-13.4* PTT-26.6 INR(PT)-1.2*
[**2163-6-7**] 01:32AM GLUCOSE-112* UREA N-70* CREAT-1.3*
SODIUM-148* POTASSIUM-4.1 CHLORIDE-115* TOTAL CO2-21* ANION
GAP-16
[**2163-6-7**] 10:00AM GLUCOSE-116* UREA N-61* CREAT-1.1 SODIUM-150*
POTASSIUM-3.8 CHLORIDE-114* TOTAL CO2-22 ANION GAP-18
[**2163-6-7**] 05:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-MOD
[**2163-6-7**] 05:30AM URINE RBC->50 WBC-[**4-11**] BACTERIA-FEW YEAST-NONE
EPI-0-2
.
.
CXR [**6-16**]):
Bilateral effusions as above with diminished lung volumes. The
bibasilar opacities are likely atelectasis, although early
developing pneumonia cannot be entirely excluded particularly in
light of leukocytosis. No failure.
.
.
TTE:
There is mild (non-obstructive) focal hypertrophy of the basal
septum. The
left ventricular cavity size is normal. Overall left ventricular
systolic
function is mildly depressed with mid-septal and mid to distal
inferior
hypokinesis. Tissue Doppler imaging suggests an increased left
ventricular
filling pressure (PCWP>18mmHg). Right ventricular chamber size
and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The
tricuspid valve leaflets are mildly thickened. The end-diastolic
pulmonic
regurgitation velocity is increased suggesting pulmonary artery
diastolic
hypertension. There is no pericardial effusion.
Brief Hospital Course:
# [**Female First Name (un) 564**] esophagitis: Admitted with poor po in setting of
thrush. EGD confirmed [**Female First Name (un) **] esophagitis. On IV fluconazole
with clotrimazole troches and nystatin for mouth care. She
should complete a 21d course of fluconazole (day 10 at
discharge).
.
# MRSA septicemia due to UTI with PICC seeding: Hypotensive
during hospital admission, requiring ICU admission for frequent
fluid boluses to maintain bp. Blood cultures subsequently grew
MRSA. Subsequent urine cultures grew MRSA. Patient was treated
with vancomycin x 7 days (d1=[**2163-6-11**]). PICC line (placed for
TPN) discontinued. TTE negative for vegetation. Surveillance
cultures since [**2163-6-10**] (date of PICC removal) no growth to date
so new PICC line placed for TPN.
.
# Acute change in mental status: Onset while on IV fluconazole
and vancomycin. Lactate/ABG/lytes/LFTs/head CT. No focal
deficit appreciated but exam limited. Head MRI showed no acute
process. Likely delirium, severe constipation, and hypothermia
contributing. After bowel regimen, manual disimpaction, warming
blanket, mental status back near baseline, per son. She
continued to have intermittent mild delerium however.
.
# Severe malnutrition: Initially started on TPN but PICC had to
be discontinued due to MRSA line infection. Subsequently,
platelets dropped, concerning for HIT. HIT ab negative and plt
rebounded spontaneously. DEspite risk of PICC and TPN
(infection, fungemia) given that a feeding tube (nasal) would be
uncomfortable for pt, it was decided after d/w family, to
replace PICC and restart TPN.
.
# Thrombocytopenia: HIT antibody negative. Fibrinogen/FDP do
not suggest DIC. Plt rebounded to normal level.
.
# CAD: On ASA. Holding BB.
.
# Afib: On ASA. Rate controlled off BB.
.
# Anemia: Suspect AOCD. HCt was variable over the admission but
not requiring transfusion. No signs of blood loss or hemolysys.
Hct was stable 2d prior to discharge at 27 but overall downward
trend. Would rpt in [**3-12**] days.
.
# DNR/DNI. Goals of care d/w son [**Name (NI) 382**] and he is leaning
towards to do not hospitalized status if she were to
decompensate again.
.
# FEN: Restarted TPN. Trials of POs were intermittently
successful with periods of aspiration at times. However, given
pt expressing desire to eat, soft diet was attempted. Due to
difficulty taking meds, her PO med regimen was pared down and
even with this she was only taking intermittent PO meds.
Medications on Admission:
Aspirin 325 mg Tablet (had been discontinued on floor [**3-11**] LE
ecchymoses)
Venlafaxine 37.5 mg
Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Neutra-Phos [**Telephone/Fax (3) 4228**] mg Packet Sig: One (1) pckt PO once a
day for 3 days.
Tylenol 325 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
Lovenox
Levothyroxine 25 mcg po qd
Prilosec
Lisinopril
HCTZ
toprol 20 qd
valium 0.5 mg po qhs
Discharge Medications:
1. Aspirin 300 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One [**Age over 90 1230**]y
(150) mg PO BID (2 times a day).
4. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
QID (4 times a day).
5. Levothyroxine 25 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Fluconazole in Saline(Iso-osm) 200 mg/100 mL Piggyback Sig:
One Hundred (100) mg Intravenous once a day for 10 days:
complete 21d course.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
PRIMARY:
Candidal esophagitis
MRSA bacteremia
MRSA UTI
Severe Malnutrition
Delerium
Discharge Condition:
Fair--afebrile, vital signs stable.
Discharge Instructions:
1. Take medications as prescribed.
2. You will be seen by the doctors at rehab. You can address
any concerns with them.
Followup Instructions:
You will be followed by the doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] Rehab
|
[
"2760",
"5990",
"496",
"42731",
"311",
"4019",
"41401",
"412"
] |
Admission Date: [**2169-3-28**] Discharge Date: [**2169-4-10**]
Date of Birth: [**2090-5-12**] Sex: M
Service: NEUROLOGY
Allergies:
Oxycontin / Lamictal / Levaquin
Attending:[**First Name3 (LF) 19817**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Per ED resident:
Mr [**Known lastname 19816**] is a 78 year-old man with long standing history
of focal epilepsy and AFib in coumadin, presented to the Ed in
status epilepticus. Patient was found this morning by his wife
in
generalized clonic seizures. The seizure lasted for 10minutes
then stopped and he had another continue another seizure. His
wife called 911, and he was brought to the closest ED where he
received 7mg of Ativan and 2g of Fosphenytoin. He continue to
present left foot clonic movements for at least more 4 hours.
In the ED [**Hospital1 18**] patient was confused, obtuned, and with
persistent left foot clonic movements.
Past Medical History:
- focal epilepsy
- history of head trauma from boxing in his youth
- cervical spinal stenosis
- BPH
- HLD
- OA
- gout
- L TKR
- HTN
- A-fib
- glaucoma
- Sleep Apnea
Social History:
Patient in his baseline walk with cane\walker,
appropriate speech, likes to read magazines.
-lives w/ girlfriend, divorced, retired
-former alcoholic and tobacco use
-no drug use
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Brother with possible history of seizures
Physical Exam:
Examination on admission (per Neuro ED resident):
VS: stable vital signs
Genl: confused obtuned. Not in acute distress
CV: Regular rate, Nl S1, S2, no murmurs, rubs, or gallops
Chest: CTA bilaterally, no wheezes, rhonchi, rales
Abd: +BS, soft, NTND abdomen
Ext: No lower extremity edema bilaterally
Neurologic examination:
Mental status: confused, non-verbal, following very simple
commands such as squiz the hands.
Cranial Nerves: Fundoscopic examination reveals sharp disc
margins. Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Extraocular movements intact bilaterally without
nystagmus. Facial movement symmetric.
Motor: Normal bulk and tone bilaterally. Moving all extremities
antigravity
Sensation: withdraw of the four limbs.
Reflexes: 2+ and symmetric throughout. Toes downgoing
bilaterally.
Gait: not tested
Exam at time of discharge:
Pertinent Results:
Labs:
[**2169-3-28**] 01:35PM BLOOD WBC-12.2* RBC-4.77 Hgb-14.9 Hct-44.4
MCV-93 MCH-31.3 MCHC-33.7 RDW-14.8 Plt Ct-192
[**2169-3-28**] 01:35PM BLOOD Neuts-83.5* Lymphs-10.4* Monos-5.2
Eos-0.5 Baso-0.3
[**2169-3-28**] 01:35PM BLOOD PT-24.3* PTT-29.6 INR(PT)-2.3*
[**2169-3-28**] 01:35PM BLOOD Glucose-122* UreaN-17 Creat-1.3* Na-144
K-3.9 Cl-102 HCO3-33* AnGap-13
[**2169-3-28**] 01:35PM BLOOD Calcium-9.1 Phos-3.1 Mg-1.6
[**2169-3-28**] 01:35PM BLOOD Carbamz-0.6*
Urine studies
[**2169-3-28**] 09:03PM URINE Blood-MOD Nitrite-POS Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2169-3-28**] 09:03PM URINE RBC-0-2 WBC-[**3-31**] Bacteri-MOD Yeast-NONE
Epi-0-2
[**2169-3-28**] 09:03PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009
Imaging/Studies:
CT head [**3-28**]:
FINDINGS: There is a small subgaleal hematoma and soft tissue
swelling
overlying the left frontal bone. There is no acute intracranial
hemorrhage,
edema, mass effect, or infarct. The ventricles and sulci are
prominent,
consistent with age-related atrophy. Supratentorial and
periventricular white
matter hypodensities reflect sequelae of chronic small vessel
ischemic
disease. There is bilateral calcification of the cavernous
carotid arteries.
There is mild mucosal thickening throughout the paranasal
sinuses. The
mastoid air cells are clear. There are no fractures. The orbits
are
unremarkable.
IMPRESSION: No intracranial hemorrhage or fracture.
CXR: [**3-28**]
FINDINGS: In comparison with study of [**2167-8-31**], there is continued
enlargement
of the cardiac silhouette without definite vascular congestion
or pleural
effusion. No evidence of acute focal pneumonia.
EEG [**3-29**]:
IMPRESSION: This telemetry captured two pushbutton activations
which
were described above. Routine sampling showed a mildly slow and
disorganized background consisting of mixed theta frequencies.
There
were no definite electrographic seizures seen on this recording;
however, retrospectively, one of the pushbuttons showed some
associated
subtle right central rhythmic activity.
EEG [**3-30**]:
IMPRESSION: This telemetry captured no pushbutton activations.
Routine
sampling showed a mildly slow and disorganized background
consisting
mostly of mixed theta frequencies. There were no areas of
prominent
focal slowing and there were no epileptiform features seen.
EEG [**3-31**]:
IMPRESSION: This telemetry captured two pushbutton activations
for
twitching with no electrographic correlate. The background
activity
showed focal slowing in the right central and left temporal
areas
suggestive of subcortical dysfunction in these areas. There were
no
clear epileptiform features
EEG [**4-1**]:
IMPRESSION: This telemetry captured no pushbutton activations.
There
were a few generalized sharp waves, but these had more of a
triphasic
appearance than a spike and slow wave morphology. The background
was
mildly slow throughout, and there was modest frontal slowing, as
well.
EEG [**4-2**]:
IMPRESSION: This telemetry captured no pushbutton activations.
Routine
sampling and automated detection programs showed no clear
epileptiform
discharges or electrographic seizures. The routine sampling
showed mild
slowing of background frequencies throughout. There were no
prominent
focal findings.
CXR [**3-30**]:
A Dobbhoff tube is coiled within the esophagus. The cardiac
silhouette is
enlarged, unchanged from prior. There is no evidence of
pulmonary or
interstitial edema. The mediastinal silhouette, hilar contours
and pleural
surfaces are normal. There is a small left pleural effusion and
associated
atelectasis. The remaining lungs are well expanded and clear.
Repeat:
FINDINGS: In comparison with the earlier study of this date, the
Dobbhoff
tube tip now lies within the upper stomach, just distal to the
esophagogastric junction. Little change in the appearance of the
heart and lungs.
CXR [**4-3**]:
FINDINGS: In comparison with the study of [**4-1**], there are lower
lung volumes,
which most likely accounts for the increased prominence of the
transverse
diameter of the heart. Basilar atelectatic changes are seen, but
no evidence
of acute focal pneumonia.
The Dobbhoff tube has been removed.
Discharge Labs
140 | 103 | 10
---------------< 95
3.3 | 29 | 1.1
Ca: 8.8 Mg: 1.8 PO4: 2.5
14.5
13.9 >-------< 190
42.5
PT: 21.4 PTT: 30.5 INR: 2.0
Brief Hospital Course:
78 yo man with PMH of focal epilepsy, status epilepticus, Afib
on coumadin, CAD, HTN, HL, OSA admitted to the neuro ICU for
focal motor seizure with generalization. At OSH/[**Hospital1 **] ED he
received 7mg IV Ativan, 2gm Dilantin, 1 gm Keppra, 100mg
Oxcarbazepine, 130mg PHB, his focal motor seizure abated.
NEURO:
At time of admission he still intermittently had left foot
clonus, a few seconds at a time. He was lethargic and
inattentive. Focal seizure exacerbation and generalization were
attributed to 1. wean of zonegran by his wife and 2. UTI.
Remaining infectious w/up was negative (CXR).
He received 1g of Keppra IV load in ICU folled by 1g [**Hospital1 **] for 1
day. Given persistent somnolence and episodes of apnea (30-45
seconds) with bradycardia, and relatively rare L foot myoclonus,
keppra was decreased to 500mg [**Hospital1 **]. On this regimen MS improved,
he became more alert and oriented to [**Hospital1 18**] and year, however
remained sedated. He was continued on oxcarbazepine 300mg [**Hospital1 **],
increase in which in the past has caused increasing fatigue and
somnolence. The Keppra was later tapered off, and the
oxcarbazepine was increased to 600mg [**Hospital1 **]. The occasional focal
left foot myoclonus was not found to have an EEG correlate.
CV. Initially volume overloaded, however, as PO intake decreased
and maintenance dose of diuretic was continued, he reached
euvolemia. He is currently on Coumadin for his Afib, and given
his current diarrhea, his INR should be followed every 2-3 days
until his diarrhea has resolved.
PULM. Multiple, frequent episodes of apnea while asleep and
sedated, at times reaching 40-45 seconds in duration with
bradycardia to 40s without desaturation. Previously diagnosed
with OSA however unable to tolerate CPAP due to discomfort.
Patient was maintained on BiPAP while at night and improved. It
was felt that significant contribution to fatigue and somnolence
were contributed to by hypercarbia
ID. UTI, treated with CFTX IV x 10 days. UCx was initially
contaminated, however did have hx of frequent UTIs. On [**4-4**] he
was noted to have rising WBC count, and diarrhea. Repeat U/A
and CXR were negative, however given the diarrhea, stool was
sent for c diff and he was started on PO vancomycin, to be
continued through [**4-17**]. Based on discussion with his PCP, [**Name10 (NameIs) **]
may benefit from standing Macrobid in the future for UTI
prevention, but will hold off on this plan for now given the
current c diff infection.
FEN: He was evaluated by speech and swallow, and approved for
regular solids, nectar thick liquids and crushed pills. He is
able to take thin liquids between meals.
Medications on Admission:
LATANOPROST [XALATAN] - 0.005 % Drops - 1 gtt ou at bedtime
METOPROLOL TARTRATE - 100mg 1 5tab once a day
SIMVASTATIN - 40 mg Tablet once a day
WARFARIN - 5 mg Tablet - once a day
Oxcarbazepine 300mg [**Hospital1 **]
Allopurinol 150mg once a day
Ranitidine 150mg [**Hospital1 **]
Amlodipine 10mg daily
Chlorthalidone 25mg [**1-28**] tab every other day
Discharge Medications:
1. Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: One (1) dose PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Oxybutynin Chloride 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID (2
times a day).
5. Simvastatin 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
6. Latanoprost 0.005 % Drops [**Month/Day (2) **]: One (1) Drop Ophthalmic HS (at
bedtime).
7. Amlodipine 5 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily).
8. Chlorthalidone 25 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO EVERY OTHER
DAY (Every Other Day).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Oxcarbazepine 600 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2
times a day).
11. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Once Daily at 4
PM.
12. Vancomycin 125 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4470**] HealthCare
Discharge Diagnosis:
Primary: Status epilepticus
Secondary: Atrial fibrillation
C difficile colitis
Hypertension
Hyperlipidemia
Discharge Condition:
Fluent speech, however will occasionally refuse to answer
questions. Able to follow commands with significant
encouragement. Can move all extremities and retracts from
pinch. Small degree of asterixes.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with status epilepticus. This was
felt to be due to tapering of one of your medications (zonegran)
and a urinary tract infection. You were started on Keppra.
With this treatment, the status resolved and you had
intermittent shaking of L foot without generalization.
The following changes were made to your medications:
- Zonegran discontinued
- Trileptal 600mg [**Hospital1 **]
If you notice any of the concerning symptoms listed below,
please call your doctor or return to the emergency department
for further evaluation
Followup Instructions:
Neurology - Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) 540**] & [**Doctor Last Name **]
Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2169-4-12**] 4:00
PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**First Name (STitle) 1313**] on Tuesday, [**4-25**] at 1pm. Phone:
[**Telephone/Fax (1) 7318**]
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2169-7-3**] 2:00
|
[
"5990",
"42731",
"V5861",
"32723",
"4019",
"2724",
"53081"
] |
Admission Date: [**2107-3-27**] Discharge Date: [**2107-4-6**]
Date of Birth: [**2038-10-7**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Salmon Oil / Nut Flavor
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Abdominal pain, nausea, vomiting, diarrhea x5days.
Major Surgical or Invasive Procedure:
[**2107-3-27**]: Exploratory laparotomy, lysis of adhesions, detorsion
of the bowel.
History of Present Illness:
Ms. [**Known lastname 111127**] is a 68 year old female who had an open AAA repair in
[**Month (only) **] of last year. She went to an Outside Hospital (OSH)
complaining of 5d of non-bloody diarrhea and 3d of gradually
worsening abdominal pain, as well as nausea/vomiting for the
past day or so. Denies fevers and chills. She underwent a CT
scan of the abdomen/pelvis at the OSH which was concerning for
small bowel ischemia, and was transferred to [**Hospital1 18**] for further
workup. On arrival here she was found to be intermittently
hypotensive to the 60s, with fluctuating sats, and
intermittently obtunded. She complains of midepigastric
abdominal pain when she is awake. But otherwise denies any
other complaints.
Past Medical History:
PMHx: HTN, COPD not on home O2 with DOE (50 ft with walker),
Depression, Obesity, Peripheral Vascular Disease, AAA and
bilateral ICA occlusion, Urinary incontinence.
.
PSHx: Cholecystectomy, appendectomy, perforated ulcers x3,
hysterectomy, bilateral total knee replacements.
Social History:
Marital Status: Divorced.
Tobacco use: Yes:
Number of cigarettes per day: 3 cigarettes.
Number of years: 1.
Previous smoker: Yes:
Number of years: 50.
Alcohol use: 1 drinks per week.
Recreational drugs: No.
Family History:
Non-contributory.
Physical Exam:
On Admission:
VS: T 98.5, HR 94, BP 102/56, RR 14, 96% on 2L
Gen: Obese. intermittently obtunded, but AAOx3 when awake
HEENT: Anicteric. Dry mucosal membranes.
Neck: No JVD. No LAD. No TM.
CV: RRR.
Pulm: CTAB.
Abd: Soft. + tender to palpation at mid epigastrium but no
rebound, no guarding
DRE: Not done
Ext: cool, clammy, distal pulses intact
.
At Discharge:
AVSS/afebrile
GEN: Elderly, obese female in NAD.
HEENT: Anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B)
COR: RRR
ABD: Protuberant. Midline incision with staples c/d/i with 2
approx. 1-1.5cm incisional wounds, which are clean, granulating.
Moist-to-dry packing placed with DSD cover. BSx4. Appopriately
tender to palpation along incision, otherwsie soft/NT/ND.
EXTREM: Left arm PICC patent/intact with clean dressing. WWP; no
c/c/e.
NEURO: A+Ox3.
Pertinent Results:
On Admission:
[**2107-3-27**] 09:07PM TYPE-ART PO2-101 PCO2-39 PH-7.30* TOTAL
CO2-20* BASE XS--6
[**2107-3-27**] 09:07PM K+-3.2*
[**2107-3-27**] 06:38PM TYPE-ART PO2-88 PCO2-38 PH-7.30* TOTAL
CO2-19* BASE XS--6
[**2107-3-27**] 06:38PM LACTATE-2.5*
[**2107-3-27**] 06:38PM freeCa-1.13
[**2107-3-27**] 04:02PM TYPE-ART PO2-105 PCO2-42 PH-7.27* TOTAL
CO2-20* BASE XS--7
[**2107-3-27**] 04:02PM GLUCOSE-166* LACTATE-2.1* K+-3.5
[**2107-3-27**] 04:02PM freeCa-1.11*
[**2107-3-27**] 11:43AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.025
[**2107-3-27**] 11:43AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.5
LEUK-NEG
[**2107-3-27**] 10:13AM TYPE-ART PO2-104 PCO2-41 PH-7.26* TOTAL
CO2-19* BASE XS--8
[**2107-3-27**] 10:13AM LACTATE-1.4
[**2107-3-27**] 07:35AM PHOSPHATE-3.9 MAGNESIUM-2.1
[**2107-3-27**] 07:35AM POTASSIUM-4.2
[**2107-3-26**] 11:10PM WBC-14.0* RBC-5.95*# HGB-18.5*# HCT-56.9*#
MCV-96 MCH-31.1 MCHC-32.6 RDW-13.7
[**2107-3-26**] 11:10PM NEUTS-88.6* LYMPHS-6.1* MONOS-5.0 EOS-0.1
BASOS-0.2
[**2107-3-26**] 11:10PM PLT COUNT-345
.
Prior to Discharge:
[**2107-4-4**] 07:05AM BLOOD WBC-12.2* RBC-3.65* Hgb-11.8* Hct-35.4*
MCV-97 MCH-32.4* MCHC-33.4 RDW-13.4 Plt Ct-384
[**2107-4-4**] 07:05AM BLOOD Glucose-87 UreaN-23* Creat-0.7 Na-142
K-3.3 Cl-101 HCO3-34* AnGap-10
[**2107-4-4**] 07:05AM BLOOD Calcium-8.6 Phos-2.8 Mg-1.9
[**2107-4-5**] 07:28AM BLOOD Vanco-13.1
.
IMAGING:
[**2107-3-26**] OSH CT scan: Lack of enhancement of small bowel
concerning for ischemia, possible closed loop obstruction vs.
mid gut volvulus, SMA patent until region of mesenteric swirling
then disappears. + Free intraabdominal fluid.
.
[**2107-4-5**] CHEST PORT. LINE PLACEM:
FINDINGS: In comparison with the study of [**4-3**], there has been
placement of a left subclavian PICC line that extends to the
upper portion of the SVC. Right IJ catheter remains in place.
Dobbhoff tube has been removed.
Brief Hospital Course:
The patient was transferred from an Outside Hospital (OSH) on
[**2107-3-26**] and was admitted to the General Surgical Service on
[**2107-3-27**] for emergent exploratory laparotomy for high grade
small bowel obstruction. In the Emergency Room, the patient was
found to be intermittently hypotensive to the 60s, with
fluctuating saturations, and intermittently obtunded. She was
intubated for inabilty to maintain sats in the ED. Early on
[**2107-3-27**], the patient underwent exploratory laparotomy, lysis
of adhesions, detorsion of the bowel, which went well without
complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient was transferred to the SICU for post-operative care. The
patient was hemodynamically stable.
.
Neuro: Post-operatively, the patient initially received
Fentanyl, then Morphine IV PRN with good effect and adequate
pain control. When tolerating oral intake, the patient was
transitioned to oral pain medications with continued good
effect. She remained neurologically intact.
.
CV: Initially hypotensive secondary to question of SIRS and
intravascular volume depletion, which responded to IV fluid
rescusitation, electrolyte repletion and administration of
albumin. Patient then became hypertensive post-operatively,
which required the initialtion of Metoprolol IV, as well as
multiple doses of IV Lasix and Hydralazine. When tolerating a
diet, IV Metoprolol was transitioned to the oral formulation and
the patient no longer required IV Hydralazine with good blood
pressure control. The patient subsequently remained stable from
a cardiovascular standpoint; vital signs were routinely
monitored.
.
Pulmonary: As above, the patient was intubated in the ED.
Post-operatively, she was kept intubated secondary to the
metabilic and respiratory acidosis. She was extubated on POD#1,
but then re-intubated on POD#4 due to hypoxemic respiratory
failure beleived to be due to an acute exacerbation of her
underlying COPD. She was started on Methylprednisone,
around-the-clock nebulizer treatments, and humidification. On
POD#5, IV Vancomycin and Zosyn were also started. She was
diuresed. These intervetions proved effective, and by POD#6, she
was extubated and subsequently remained stable. Good pulmonary
toilet, early ambulation and incentive spirrometry as well as
use of her home inhalers and PRN nebulizer treatments were
continued throughout hospitalization. At discharge, she was on
[**1-29**] liters by nasal cannula to maintain her SaO2 >93-94%.
.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. The patient self-discontinued her NGT on POD#2, which
was replaced, but then later removed on POD#4. A dobbhoff was
placed, and tubefeeds started on POD#5. On POD#6, she was
started on sips. Her diet was progressively advanced to regular
by POD#7, which was well tolerated, and tubefeeds discontinued.
Foley was discontinued on POD#8; she subsequently voided without
problem. Patient's intake and output were closely monitored, and
IV fluid was adjusted when necessary. Electrolytes were
routinely followed, and repleted when necessary.
.
ID: Given re-intubation due to possible COPD exacerbation versus
pneumonia, the patient was empirically started on IV Vancomycin
and Zosyn on POD#5 after the patient was pan-cultured. Sputum
gram stain revealed GPRs, GNRs, and GPs and the urine culture
grew MRSA. Sputum also later grew E. coli and MRSA. It was
determined that the patient would require IV Vancomycin and
Cipro until [**2107-4-15**], thus a PICC line was placed. The
patient's white blood count and fever curves were closely
watched for signs of infection. Wound care: After staples
removed on POD#9, two incisional wounds opened up along inferior
aspect, requiring moist-to-dry packing, which continued at
discharge. Wounds were clean and granulating.
.
Endocrine: The patient's blood sugar was monitored throughout
his stay; sliding scale insulin was administered when indicated.
.
Hematology: The patient's complete blood count was examined
routinely; no blood transfusions were required.
.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with assitance, voiding without assistance, and
pain was well controlled. She was discharged to an extended
care faciltiy for further nursing care and rehabiliation. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan.
Medications on Admission:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Hydrochlorothiazide dose unknown
12. Triamterene dose unknown
13. Chantix
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
3. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
4. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
6. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
7. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
11. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days: Completion date: [**2107-4-15**].
12. HydrALAzine 10 mg IV Q6H:PRN SBP more than 160
13. DiphenhydrAMINE 12.5-25 mg IV Q6H:PRN prn agitation
start with 12.5mg dose please
14. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
15. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous every twelve (12) hours for 10 days: Completion
Date: [**2107-4-15**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] at [**Location (un) 701**]
Discharge Diagnosis:
1. Ischemic bowel from the adhesions with volvulus.
2. COPD with exacerbation.
3. Metabolic and respiratory acidosis.
4. Acute renal failure.
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**6-6**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8318**], MD Phone:[**Telephone/Fax (1) 2359**]
Date/Time:[**2107-4-21**] 11:45. Location: [**Hospital Ward Name **] 3, [**Last Name (NamePattern1) **],
[**Hospital Ward Name 517**], [**Hospital1 18**] [**Location (un) 86**].
.
Please call ([**Telephone/Fax (1) 6693**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) 17025**] (PCP) in [**3-2**] weeks.
.
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7145**] ORTHOPEDIC PRIVATE PRACTICE
Phone:[**Telephone/Fax (1) 11262**] Date/Time:[**2107-8-12**] 11:30
Completed by:[**2107-4-6**]
|
[
"0389",
"51881",
"5849",
"2762",
"5990",
"99592",
"3051",
"4019",
"311",
"2859"
] |
Admission Date: [**2195-7-5**] Discharge Date: [**2195-7-13**]
Date of Birth: [**2160-6-16**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 598**]
Chief Complaint:
s/p Motorcycle crash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
35 yo male s/p motorcycle crash who was transferred from another
hospital. He was driving a motorcycle on the way to work and
slid to avoid hitting a
squirrel. There was no loss of consciousness. At [**Hospital3 1280**]
he had a head CT, neck CT, chest CT, torso CT. The findings
on the CT or a left small pneumothorax rib fx rib #[**6-7**] on
the left and ribs #3 through 5 fracture on the right. There
is also left scapular fracture and a small left
pneumothorax. The abdominal CT scan was negative.
Past Medical History:
PSH: tonsillectomy, and eardrum tubes when young
Family History:
Noncontributory
Pertinent Results:
[**2195-7-5**] 05:04PM GLUCOSE-96 UREA N-9 CREAT-0.7 SODIUM-143
POTASSIUM-4.7 CHLORIDE-110* TOTAL CO2-24 ANION GAP-14
[**2195-7-5**] 05:04PM CALCIUM-8.6 PHOSPHATE-3.8 MAGNESIUM-1.9
[**2195-7-5**] 05:04PM WBC-13.3* RBC-4.46* HGB-14.2 HCT-39.4* MCV-88
MCH-31.8 MCHC-36.0* RDW-13.9
[**2195-7-5**] 05:04PM PLT COUNT-298
Left scapule xray
IMPRESSION:
1. Subcutaneous emphysema.
2. Comminuted scapular fracture which may extend to the inferior
glenoid.
3. Multiple mildly displaced rib fractures.
Brief Hospital Course:
He was admitted to the Acute Care service. Orthopedics was
consulted for the scapula fracture which was managed non
operatively. It is being recommended that he wear a sling for
comfort and when out of bed.
He required supplemental oxygen for his low saturations related
to his rib fractures. His IS volumes were low and his sats did
not improve significantly. He was also noted with thick green
sputum production and an elevated WBC of 15. Given his exam and
these findings he was started on Levaquin for 7 days. A chest
xray was obtained in the morning of HD # 4 showing a moderate
sized left hemopneumothorax. A left chest tube was placed with
~275 cc's bloody output. The output decreased significantly and
he was placed to water seal on the next morning. A CXR was done
which did not show any pneumothorax. The chest tube was removed
on [**7-11**] post pull chest xray showed a residual small
pneumothorax. Clinically he showed improvement, his O2 sats were
in the high 90's and he was without any complaints of dyspnea.
Also of note his cough had improved and there was no further
sputum production.
He did experience significant pain control issues during his
stay. Several adjustments to his pain medication regimen were
made. Ultram and Toradol were added to the narcotic pain
medication. At time of discharge his pain was well controlled.
He was seen and evaluated by Physical therapy and will require
outpatient Physical therapy once discharged.
Medications on Admission:
None
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours).
3. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
4. Dilaudid 4 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours.
Disp:*80 Tablet(s)* Refills:*0*
5. ketorolac 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
6. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
7. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.
8. Outpatient Physical Therapy
Dx: s/p Motorcycle crash w/ Left scapula fracture and rib
fractures.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Motorcycle crash
Injuries:
Left scapula fracture
Rib fracture
Pneumonia
Hemopneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after a motorcycle crash where
you sustained a left scapula (shoulder) fracture and rib
fractures. These injuries did not require any operations. It is
being recommended that you wear a sling when out of bed and to
limit weight bearing on the left arm/shoulder. It is OK to do
range of motion exercises as instructed by the therapist. You
will also need to go to outpatient Physical therapy for ongoing
treatment.
You were also treated for a suspected pneumonia related to your
rib fractures.
A finding on your chest xray on the 4th hopsital day showed a
collection of blood inth long which required that a chest tube
be placed to drain the blood. Xrays were followed closely and
the tube was eventually removed.
* Your accident caused rib fractures which can cause severe
pain and subsequently cause you to take shallow breaths because
of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Followup Instructions:
Follow-up in orthopaedic clinic as an outpatient with Dr.
[**Last Name (STitle) **] in 2 weeks. Call [**Telephone/Fax (1) 1228**] for an appointment.
Follow up in Acute Care Clinic next week. Call [**Telephone/Fax (1) 600**] for
an appointment. Inform the office that you will need a standing
end expiratory chest xray for this appointment.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]
Completed by:[**2195-7-13**]
|
[
"486"
] |
Admission Date: [**2107-8-8**] Discharge Date: [**2107-8-24**]
Date of Birth: [**2032-5-11**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
elevated PCWP, severe MR/TR found intraoperatively
Major Surgical or Invasive Procedure:
Trans esphageal echocardiogram
History of Present Illness:
Pt is a 75M with h/o CAD s/p CABG in [**2089**] (LIMA to LAD, SVG to
D1, SVG to RCA), DMII and critical AS who was scheduled for
cardiac cath and aortic valve replacement two days ago ([**2107-8-8**])
and found to have elevated PCWP and severe TR/MR [**Last Name (Titles) 25299**]. He is
transferred to CCU for volume status to be optimized before
repeat AVR.
.
Pt was admitted to [**Hospital1 **] in [**2107-6-11**] with dizziness, nausea, and
vomiting. He was also experiencing episodes of unsteady gait [**3-15**]
verigo. He was found to have severe aortic stenosis on echo
during that admission (valve area <0.8cm2)and recommended to
return at the end of [**Month (only) **] for aortic valve replacement. He was
also diagnosed with a comm acquired pneumonia and completed a
course of abx. After discharge, pt went to rehab for 2 weeks and
then returned home where he continued to have vertigo and
fatigue. He came in on [**8-4**] for scheduled cath pre-op and per pt
showed that CABG vessels were patent (need to confirm this on
official report). He was taken to the OR yesterday and per
report found to have unexpected wide open with dilated RV on
TEE. Surgery aborted procedure and he was returned to ICU.
Reported PA pressures were 80-90.
.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
# Aortic stenosis (critical AS with area <0.8cm2 per today's
ECHO)
# CAD s/p CABG in '[**89**] (LIMA to LAD, SVG to D1, SVG to RCA)
3. OTHER PAST MEDICAL HISTORY:
# Essential tremor
# Aortic stenosis (critical AS with area <0.8cm2 per today's
ECHO
# CAD s/p CABG in '[**89**]
# Diabetes Mellitus Type 2
# Hypertension
# Hyperlipidemia
# Essential tremor
Social History:
Retired particle physicist. Widower, lives alone at home in
[**Location (un) 1157**], MA. denies T/E/D.
Family History:
Non-Contributory
Physical Exam:
Gen: pt laying in bed in NAD
CV: 3/6 systolic ejection murmur at upper right sternal border
and left lower sternal border, RRR, nl S1/S2
Chest: cta bilaterally
Abd: soft/NT/ND
Ext: no LE edema
Pertinent Results:
Admission labs:
.
[**2107-8-8**] 06:50PM BLOOD WBC-6.6 RBC-4.17* Hgb-12.5* Hct-38.1*
MCV-91 MCH-30.0 MCHC-32.8 RDW-15.0 Plt Ct-242
[**2107-8-8**] 06:50PM BLOOD PT-12.5 PTT-24.5 INR(PT)-1.1
[**2107-8-8**] 06:50PM BLOOD Glucose-91 UreaN-21* Creat-0.8 Na-141
K-4.3 Cl-104 HCO3-31 AnGap-10
[**2107-8-8**] 06:50PM BLOOD ALT-37 AST-27 LD(LDH)-207 AlkPhos-64
TotBili-0.5
[**2107-8-8**] 06:50PM BLOOD Albumin-3.7
[**2107-8-9**] 12:17PM BLOOD Calcium-8.6 Phos-4.0 Mg-1.8
[**2107-8-8**] 06:50PM BLOOD %HbA1c-9.2* eAG-217*
.
.
Other results:
[**2107-8-13**] 05:31AM BLOOD TSH-3.6
.
Carotid dopplers [**2107-8-9**]: Less than 40% stenosis of the
bilateral extracranial internal carotid arteries.
.
Echo [**2107-8-11**]: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. There is mild regional left
ventricular systolic dysfunction with basal to mid inferior and
inferolateral hypokinesis. Overall left ventricular systolic
function is mildly depressed (LVEF= 40 %). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size is normal. with
mild global free wall hypokinesis. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Moderate (2+) mitral regurgitation is
seen. Due to the eccentric nature of the regurgitant jet, its
severity may be significantly underestimated (Coanda effect).
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2107-7-4**],
the findings are similar with critical aortic stenosis, moderate
mitral regurgitation (maybe understimated), and moderate
estimated pulmonary artery systolic hypertension.
.
CATH [**2107-8-8**]: PA 86/31, CVP 25, PAD 35, [**Doctor First Name 1052**] 52; LAD occluded mid
vessels after 2 small diag branches, diags had 70-80% stenosis,
LCX occluded mid vessel, OM1 99% stenosis an distal vessel
receives collateral flow from RCA and diag (both supplied by
SVG), other OM branches occluded, AV groove continues and
supplies only small LV branch that fills base of heart. RCA
cocluded proximally, SVG-PDA widely patent, PL fills
retrogradely, colalterals supplied from PL to OM3, SVG-diag
widely patent, supplies collateral to OM2, LIMA-LAD widely
patent
.
.
Discharge Labs:
[**2107-8-24**] 06:40AM BLOOD WBC-9.1 RBC-3.54* Hgb-10.9* Hct-31.4*
MCV-89 MCH-30.7 MCHC-34.6 RDW-16.2* Plt Ct-316
[**2107-8-24**] 06:40AM BLOOD Glucose-54* UreaN-16 Creat-1.0 Na-137
K-4.3 Cl-98 HCO3-32 AnGap-11
Brief Hospital Course:
Pt is a 75 y/o man with CAD s/p CABG in [**2089**] (LIMA to LAD, SVG
to D1, SVG to RCA), DMII and critical AS who was scheduled for
elective AVR [**2107-8-6**] and found intra-operatively to have wide
open MR/TR on echo and elevated PA pressures. Procedure was
aborted and he was transferred to CCU for medical optimization.
.
1) Aortic stenosis, MR, TR - Pt had documented critical AS with
an aortic valve area of 0.6cm, a peak gradient of 58mm Hg (mean
gradient 34mm Hg), and peak velocity 3.8m/sec. Due for aortic
valve replacement but found to be hemodynamically unstable
intra-op. While under the care of the CCU, he was diuresed to
LOS fluid balance of -13L. His dry weight was 71kg, down from
76kg on admission. TTE [**8-11**] showed 2+ MR and 1+ TR. The patient
had hoped to go home for a few weeks before a second attempt at
AVR, but given the severity of his AS and how well optimized the
patient appeared hemodynamically, the decision was made to
attempt surgery before d/c. On [**2107-8-18**], the day before surgery
was anticipated, a Swann catheder was placed to asses
hemodynamics. This revealed PAP 90/4, RV 87/27, and wedge 23.
Given this evidence of persistantly severe MR and pulmonary
hypertension, the decision was made to postpone surgery. Cardiac
cath and balloon valvuloplasty were done on [**8-22**] with valve area
improved to 0.74 with 1+ AR. Pt was discharged on lasix Po for
further diuresis and will return in [**Month (only) 216**] for repeat evaluation
for AVR.
.
2) atrial fibrilation - First noted [**8-12**], intermittent,
responsive to IV BBlocker. Patient was hemodynamically stable
and asymptomatic during these episodes. No known Hx of A Fib. EP
was consulted and recommended 3 weeks of amiodorone 400mg daily,
and then amiodorone 200mg daily indefinitely. Pt was on heparin
drip during most of hospital course as surgery was anticipted
with the plan to bridge to coumadin before d/c. TSH checked to
look for underlying causes of afib, but was normal. Metoprolol
25mg [**Hospital1 **] also added for rate control. Pt was started on coumadin
prior to discharge and INR was 1.2. He will be followed by Dr. [**Name (NI) 25300**] office for coumadin adjustment.
.
3) CAD - Pt is s/p CABG with graft vessels found to widely
patent on cath during admission. ASA 81mg daily and lipitor 80mg
QHS were continued throughout admission.
.
4) DM ?????? Pt was follwed by the [**Hospital **] clinic who adjusted his
basal dose of Lantus with humolog sliding scale.
.
5) Dental - Dental consulted to evaluate what appeared to be a
hematoma in the patient's mouth, likely secondary to trauma
(biting). Recommended clorhexidine mouth rinses and abx
prophylaxis (clinda, given PCN allergy) for surgery. If not
resolved in [**8-20**] days, pt should see dentist as an outpt.
.
CODE: Presumed full
Medications on Admission:
.ASA 81mg 2 tabs daily
Lisinopril 2.5mg daily
Propanolol 60mg daily
Lipitor 80mg at night
Ativan 0.5mg at night
Calcium 600mg with Vitamin D 400IU daily
Multivitamin one daily
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
Disp:*900 ML(s)* Refills:*2*
6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 17 days.
Disp:*36 Tablet(s)* Refills:*0*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
start on [**2107-9-11**].
Disp:*30 Tablet(s)* Refills:*2*
8. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
please check INR, chem-7 on Friday [**9-26**] and call results to Dr.
[**Last Name (STitle) 25301**] at [**Telephone/Fax (1) 25302**] and fax to [**Telephone/Fax (1) 25303**] thanks
11. Multiple Vitamin Tablet Sig: One (1) Tablet PO once a
day.
12. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One
(1) Tablet PO once a day.
13. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
14. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous every am.
15. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous in the evening.
16. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous four times a day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Aortic Stenosis
Atrial Fibrillation
Acute on Chronic Diastolic Congestive Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted on [**8-8**] for an expected aortic valve
replacement but your heart function was not good enough to have
the operation so you had a valvuloplasty instead. This has
opened your aortic valve temporarily and we hope that your heart
function will improve now so that you may be able to have the
valve replacement this summer. You also were found to be in
atrial fibrillation, a common heart arrhythmia that increases
your risk of stroke. You were started on Warfarin (coumadin) to
thin your blood and help to prevent a stroke. You will need to
get your blood checked frequently to monitor the blood level of
this medicine. Dr. [**Last Name (STitle) **] will tell you how much warfarin to
take daily.
Other medication changes:
1. Start Amiodarone to help your heart stay in a normal rhythm.
You are getting a loading dose of 400 mg daily but will decrease
to 200 mg daily in the next few weeks.
2. Start Warfarin (coumadin) to prevent a stroke. The goal blood
level of Warfarin is 2.0-3.0. Please take this medicine every
day with dinner
3. Stop taking Propanolol, take Metoprolol instead to slow your
heart rate.
4. Start taking Chlorhexadine mouthwash to prevent bacteria
buildup in your mouth
5. Start taking Furosemide (lasix) to decrease the pressures in
your heart. Please call Dr. [**Last Name (STitle) **] if you feel very thirsty,
light headed or dizzy, the dose may need to be adjusted.
6. Go back to your home insulin regimen, The [**Last Name (un) **] Doctors [**Name5 (PTitle) 20554**] [**Name5 (PTitle) 17773**] a printout of the scale this am. Decrease your evening
Glargine dose to 18 units at night, continue with 20 units in
the morning.
7. You will need to have labs checked on Friday, the VNA can
draw those labs for you and Dr. [**Last Name (STitle) 25301**] will get the results.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in 1 day or 6 pounds in 3 days.
.
You will get a call from Dr.[**Name (NI) 25304**] office to move your follow
up appts to an earlier time. Dr. [**Last Name (STitle) **] feels that [**10-3**] appt is
fine so you will keep this. You will need to have a TEE (trans
esophageal echocardiogram) before your cardiology appt, someone
from [**Hospital1 18**] will call you to set this up.
Followup Instructions:
PCP [**Name Initial (PRE) **]:Monday, [**9-5**] at 2pm
Name:[**Name6 (MD) **] [**Name6 (MD) **],MD
Address: [**Street Address(2) 25305**], [**Hospital1 **],[**Numeric Identifier 25306**]
Phone: [**Telephone/Fax (1) 25302**]
Department: CARDIAC SERVICES
When: MONDAY [**2107-10-3**] at 1:40 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2107-8-30**]
|
[
"41401",
"V4581",
"42731",
"4168",
"4019",
"4280",
"V5867",
"2724",
"2859"
] |
Admission Date: [**2173-2-26**] Discharge Date: [**2173-3-3**]
Date of Birth: [**2107-8-7**] Sex: M
Service: MEDICINE
Allergies:
Lipitor / Augmentin / Golytely
Attending:[**First Name3 (LF) 983**]
Chief Complaint:
Dyspnea, tachypnea
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
The patient is a 65-year-old man with a history of MI one year
ago and placement of a biventricular IC device who presented to
[**Hospital3 **] earlier today with acute dysnea and tachypnea.
At [**Hospital1 **], the patient was seen to have bilateral pulmonary
edema and was started on levofloxacin and a nitroglycerin drip.
Cardiology at [**Hospital1 18**] was consulted, and the patient was
transferred for further work-up after he required intubation at
[**Hospital3 **].
.
In the ED, Cardiology was again consulted on arrival of patient.
Again, inferior Q waves seen and a new right bundle branch block
and T waves in anterior leads. Overall, however, they felt that
the patient's clinical picture was more consistent with sepsis
than with acute coronary syndrome. The patient's antibiotics
were expanded from levofloxacin to vancomycin, levofloxacin, and
flagyl. In addition to possible pneumonia, the patient's
urinalysis was suggestive of infection. The patient's blood
pressures were in the 90s SBP, so his nitro gtt was
discontinued. Because his blood pressure did not recover, the
patient was given a right IJ and started on norepinephrine.
Before transfer to the MICU, the patient was sent for a CTPA,
given concern for pulmonary embolism.
.
On arrival to the MICU, the patient is intubated and sedated.
Past Medical History:
1. Ischemic Cardiomyopathy with EF 15-20% range. Class III/IV
heart failure.
2. STEMI (syncope x 2, sob) [**2172-8-4**] s/p cath with 3VD requiring
IABP. S/p CABG x 3 (LIMA-LAD, SVG-OM2, SVG-rPDA) and MV repair
(28 mm [**Last Name (un) 3843**]-[**Known firstname **] full annuloplasty ring) c/b
mediastinal
bleeding and taken back to OR for re-exploration x 2. Prolonged
hospitalization/rehab and finally returned home in late
[**Month (only) 1096**].
Patient states stil has grounding wire in his chest that they
were unable to remove and just cut below his skin.
3. [**Hospital1 **] ER [**2172-11-29**] with left sided weakness and vertigo.
CT negative. US without significant carotid stenosis. Mildly
hypotensive and medications Spironolactone and Lasix were
discontinued. (?) CVA.
4. Atrial Fibrillation: patient denies
5. Hx of NSVT
6. Recent admit to [**Hospital1 **] with presyncope, orthostasis, and
volume depletion
7. Hyperlipidemia- intolerant of statins
8. Vertigo - improved on Meclezine which he has stopped
9. Spina Bifida
10.Hemorrhoids/rectal bleeding
11.Hiatal Hernia
12.Chronic constipation/retained stool by colonoscopy/fecal
incontinence
13.Sinusitis/allergic rhinitis
14.Asthma
15.Bone spur
16.Dislocated shoulder
17.BPH
18.Eczema
19.Sleep Apnea- does not tolerate CPAP
20.Insomnia
21.Blepharitis
22.Neck surgery to remove a "gland"
Social History:
Lives alone. He does not have any children. He
has very supportive neighbors. Retired from the post office.
He
does not use any assistive devices.
Family History:
Father died of stroke at age 84. Mother died at age 65 with
asthma. Brother had MI and CABG at age 46.
Physical Exam:
Admission physical exam:
General: Intubated, sedated
HEENT: Sclera anicteric, intubated, pinpoint pupils but reactive
Neck: supple, JVP not readily apprehended
Chest: Midsternal scar
CV: Regular rate and rhythm, normal S1 + S2, quiet heart sounds,
no murmurs auscultated
Lungs: Mild crackles at bases to anterior auscultation,
diminished sounds on lower left
Abdomen: soft, non-tender, non-distended, bowel sounds present
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses.
Neuro: Intubated, sedated, unable to follow commands.
Pertinent Results:
Admission labs:
[**2173-2-26**] 01:41AM BLOOD WBC-10.2 RBC-4.42* Hgb-12.9* Hct-40.9
MCV-93 MCH-29.1 MCHC-31.5 RDW-13.4 Plt Ct-454*
[**2173-2-26**] 05:13AM BLOOD Glucose-110* UreaN-20 Creat-1.2 Na-136
K-4.1 Cl-109* HCO3-18* AnGap-13
[**2173-2-26**] 05:13AM BLOOD Digoxin-1.3
[**2173-2-26**] 01:43AM BLOOD Glucose-121* Lactate-2.4* Na-138 K-4.2
Cl-108 calHCO3-16*
.
Discharge labs:
[**2173-3-3**] 05:15AM BLOOD WBC-5.5 RBC-4.16* Hgb-11.8* Hct-37.1*
MCV-89 MCH-28.5 MCHC-31.9 RDW-13.5 Plt Ct-422
[**2173-3-3**] 05:15AM BLOOD Glucose-109* UreaN-17 Creat-0.7 Na-139
K-3.6 Cl-106 HCO3-21* AnGap-16
.
Microbiology:
Rapid respiratory virus screen and culture [**2173-3-1**]: POSITIVE FOR
PARAINFLUENZA TYPE 3
.
Imaging:
.
CTA chest [**2173-2-26**]:
1. Right lower lobe pneumonia with a small parapneumonic
effusion.
2. Complete collapse of the left lower lobe and moderate left
pleural effusion. While the left lower lobe collapse may be due
to mucoid mpaction, the presence of mediastinal and hilar
lymphadenopathy raises suspicion for an endobronchial or hilar
lesion. However, this is difficult to assess at this point since
the patient's lymphadenopathy may be reactive and due to
pneumonia. As a result, a dedicated Chest CT with contrast is
recommended after resolution of pneumonia for further
characterization. Furthermore, consultation with pulmonology is
recommended as the presence of an endobronchial lesion needs to
be excluded.
3. No evidence of pulmonary embolism or acute aortic injury.
Brief Hospital Course:
65 yo M with CAD s/p MI and CABG, CHF (EF 15%), BiV ICD,
initially admitted to the MICU with pneumonia, complicated by
septic shock. The patient was treated with antibiotics, with
resolution of his respiratory failure and septic physiology.
Antibiotics were narrowed to just levofloxacin, and the patient
was discharged with a plan for a total 8-day course.
.
# Community-acquired pneumonia, complicated by septic shock and
respiratory failure: The patiented presented with shortness of
breath. He developed respiratory failure and hypotension,
requiring intubation and norepinephrine gtt. Chest imaging
showed right lower lobe pneumonia and complete collapse of the
left lower lobe. The patient was treated with vancomycin,
cefepime, levofloxacin, with improvement in his hemodynamics and
respiratory status. Cultures were notable only for
parainfluenza. Cefepime was stopped on [**3-1**]. Vancomycin was
stopped on [**3-2**]. The patient was discharged on [**3-3**], with a plan
to treat with levofloxacin until [**3-7**].
.
# Respiratory failure: This was felt to be multifactorial, with
pneumonia, sepsis, pleural effusion, and pulmonary edema all
contributed. The patient was intubated for several days before
being extubated on [**2-28**]. Over the next several days, he was
weaned off of supplemental oxygen and discharged on room air.
.
# Septic shock: The patient developed hypotension, requiring
norepinephrine gtt. He blood pressure eventually stabilized, and
he was transitioned out of the ICU.
.
# Left lower lobar collapse: CTA showd left lower lobar collapse
and mediastinal/hilar lymphadenopathy, concerning for an
endobronchial or hilar lesion. Repeat chest CT following
resolution of the pneumonia, and pulmonary consultation were
recommended. The inpatient team spoke with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
the patient's PCP, [**Name10 (NameIs) 4120**] the need to follow up on this
finding. The possibility of a tumor and the need for prompt
follow-up was also discussed with the patient.
.
# Ischemic cardiomyopathy, with chronic systolic heart failure:
EF is 15-20%. Initially there was concern for pulmonary edema,
and the patient was started on a nitroglycerin gtt.
Subsequently, the patient became hypotensive, at which point
nitroglycerin was stopped, fluids were given, and the patient
was started on a norepinephrine gtt. As the patient improved, he
was diuresed. Carvedilol was restarted and lisinopril was added.
The patient was discharged with close cardiology and primary
care follow-up.
.
# CAD s/p CABG: MI was ruled out with serial enzymes. Aspirin
was continued.
.
# History of atrial fibrillation: The patient remained in sinus
rhythm. His cardiology was contact[**Name (NI) **] to discuss the patient's
stroke risk, and consideration of anticoagulation. Together with
cardiology, the decision was made to hold off on anticoagulation
for now and have this addressed at the time of outpatient
follow-up.
.
# Urinary retention/Benign prostatic hypertrophy: The patient's
Foley catheter was removed upon transfer out of the ICU.
However, the patient developed urinary retention, requiring
replacement of the Foley. The patient was treated with
finasteride and tamsulosin. The Foley was removed on the day of
discharge, and the patient was able to void, with a 130 cc
residual on bladder scanning. The patient was discharged on
Avodart and tamsulosin. Outpatient urology follow-up was
arranged.
Medications on Admission:
Lasix 20mg
pantoprazole 40mg
tamsulosin 0.4 mg
lisinopril 5mg
Potassium 10meq
spironolactone 25mg
Discharge Medications:
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
2. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
4. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. nasocort AQ Sig: Two (2) sprays Nasal once a day.
6. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation every 4-6 hours as
needed for shortness of breath or wheezing.
8. cyclosporine 0.05 % Dropperette Sig: One (1) drop each eye
Ophthalmic twice a day.
9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO once a day.
15. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
16. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
17. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*1 box* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
guardian healthcare
Discharge Diagnosis:
Primary:
1. Septic shock.
2. Community-acquired pneumonia, complicated by septic shock.
3. Left lower lung lobe collapse.
4. Bilateral pleural effusions
5. Urinary retention
.
Secondary:
1. Chronic systolic heart failure
2. Atrial fibrillation
3. Coronary artery disease
4. Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital with low blood pressure and respiratory
failure. You needed a breathing tube. You were found to have
pneumonia and were treated with antibiotics. As you improved,
you were able to breath without the breathing tube, and your
blood pressure improved as well.
.
You are being discharged on an antibiotic called levofloxacin
that you can take by mouth for the next 4 days. It is very
important that you complete your course of antibiotics.
.
While in the hospital, you had a CT scan of your chest, which
showed collapse of the left lower lobe of your lung, as well as
some enlarged lymph nodes in your chest. This could be related
to your pneumonia, but it could also indicate a lung tumor. For
this reason, you will need repeat CT scan of your chest when
your pnemonia has resolved. We have discussed this with Dr.
[**First Name (STitle) **], and you should speak with her about this at the time of
follow-up.
.
You had some difficulty urinating, requiring replacement of your
Foley catheter. You were started on a medication called Flomax
(tamsulosin). You are being discharged on the Flomax, as well as
the Avodart, which you were taking perviously. We have arranged
for you to follow up with your urologist. Your Foley cathether
was removed prior to discharge, and you were able to urinate,
although you had some mild retention of urine. If you are unable
to urinate, you need to go to the emergency room.
.
We added a new medication called lisinopril for your heart
failure. We spoke with your cardiologist and your primary care
doctor, who will further adjust your medications as needed. Due
to started lisinopril, you will need to have your kidney
function and electrolytes checked in [**11-30**] weeks. Please discuss
this with your primary care doctor.
.
There are some changes to your medications:
1. Start lisinopril 2.5 mg daily (for blood pressure and heart
failure)
2. Start Flomax (tamsulosin) 0.4 mg at bedtime (for urinary
problems)
3. Continue levofloxacin (antibiotic for pneumonia) for 4 more
days.
4. Start ipratropium (nebulizer) every 6 hours as needed for
wheezing or shortness of breath.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) 1877**],[**First Name3 (LF) 539**] E.
Location: [**Hospital3 **] INTERNAL MEDICINE
Address: [**Street Address(2) 4472**] [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**]
Phone: [**Telephone/Fax (1) 4475**]
Appointment: MONDAY [**3-8**] AT 4:30PM
**You also said you had an appointment with your primary care
doctor tomorrow [**2173-3-3**] at 10:45 a.m. Please call your PCP
tomorrow morning to clarify when your appoinment is.
**Please speak with your PCP about the need for a referral to a
Pulmonologist within 2-4 weeks of your discharge from the
hospital.**
.
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Specialty: CARDIOLOGY
Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES
Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 4474**]
Phone: [**Telephone/Fax (1) 4475**]
Appointment: FRIDAY [**4-9**] AT 2:15PM
.
Name: [**Last Name (LF) **], [**Name8 (MD) **] MD
Specialty: UROLOGY
Location: [**Hospital **] HOSPITAL
Address: [**Location (un) **], STE#2206 [**Location (un) **], [**Numeric Identifier 60377**]
Phone: [**Telephone/Fax (1) 92423**]
Appointment: TUESDAY [**3-11**] AT 9AM
|
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"2859"
] |
Admission Date: [**2191-1-31**] Discharge Date: [**2191-2-10**]
Date of Birth: [**2129-4-12**] Sex: F
Service: Liver Transplant Surgery
ADMISSION DIAGNOSIS:
End stage renal disease due to alcoholic cirrhosis
complicated by portal hypertension and hepatic
encephalopathy.
End stage renal disease due to alcoholic cirrhosis
complicated by portal hypertension and hepatic
encephalopathy, status post orthotopic liver transplant.
ADMISSION HISTORY AND PHYSICAL: Mrs. [**Known lastname 12271**] is a 62
year-old female with a past medical history significant for
end stage renal disease due to alcoholic cirrhosis
and ascites. She was most recently admitted to the hospital
in late [**2190-12-15**] with mental status changes. She
underwent diagnostic paracentesis of her ascites and was
found to have greater then 500 white blood cells, though she
did not meet criteria for spontaneous bacterial peritonitis,
and gram stain and culture revealed no organisms. She was
started at the time on oral Ciprofloxacin, which she is
currently still taking and her mental status cleared and has
remained stable since that time. She reports no further
issues or problems since this discharge on the [**1-14**]. She now presents to the hospital
preoperatively for an orthotopic liver transplant.
PAST MEDICAL HISTORY:
1. End stage renal disease.
2. Alcoholic cirrhosis.
3. Portal hypertension.
4. Hepatic encephalopathy.
5. Ascites.
6. Hypothyroidism.
7. Type 2 diabetes mellitus.
MEDICATIONS ON ADMISSION:
1. Humalog 75/25 30 units subQ q.a.m.
2. Humalog 75/25 24 units subQ q.p.m.
3. Propanolol 10 mg twice a day.
4. Levothyroxine 75 micrograms once per day.
5. Calcium carbonate 500 mg three times a day.
6. Zantac 150 mg twice a day.
7. Lactulose 60 milliliters twice a day.
8. Folic acid 1 mg once per day.
9. Vitamin D 400 units once per day.
10. Ciprofloxacin 500 mg once per day.
ALLERGIES: Codeine.
SOCIAL HISTORY: Mrs. [**Known lastname 12271**] reports a sixty pack year
tobacco history, which she quit ten years ago. She also
reports a heavy alcohol history, which she quit approximately
two and a half years ago. She currently lives in [**Hospital3 12272**].
FAMILY HISTORY: Noncontributory.
INITIAL PHYSICAL EXAMINATION: Mrs. [**Known lastname 12271**] was found to be
alert and oriented and in no acute distress. Pupils are
equal, round, and reactive to light and accommodation.
Extraocular movements intact. Her neck was supple with
trachea in the midline and no jugulovenous distention. Her
heart showed a regular rate and rhythm with a normal S1 and
S2 and no murmurs, rubs or gallops. Her lungs were clear to
auscultation bilaterally. Abdomen was soft, quite distended
and nontender. Extremities showed 1+ edema bilaterally and
were warm and well perfuse. She had no focal neurological
deficits at that time.
LABORATORIES ON ADMISSION: CBC showed a white blood cell
count of 8.2 with a hematocrit of 28.6 and a platelet count
of 87. PT was 18.7 with a PTT of 40.6 and an INR of 2.3.
Fibrinogen was 133. Chemistries on admission showed a sodium
of 139, with a potassium of 4.2, chloride 113 with a
bicarbonate of 15 and a BUN and creatinine of 48 and 3.0 and
a blood glucose of 205. Liver function tests were
significant for an ALT of 30, AST 43, alkaline phosphatase of
134 with a total bilirubin of 2.6. Amylase was 66, lactate
dehydrogenase was 269 and lipase was 107. The albumin 3.7,
calcium 9.3, phosphate 5.7, magnesium 2.5, and uric acid 9.6.
HOSPITAL COURSE: Mrs. [**Known lastname 12271**] was admitted to the hospital
and subsequently taken to the Operating Room later that night
where she underwent an orthotopic liver transplant. Please
refer to the dictated operative note for full details of this
procedure. She tolerated the procedure well, receiving 6
units of packed red blood cells, 8 units of fresh frozen
platelets, 12 units of platelets, and 3800 cc of crystalloid
in the Operating Room. She was subsequently transferred to
the Surgical Intensive Care Unit in stable condition. She at
this time was on a Propofol drip for sedation and was started
on Fluconazole, Bactrim and insulin drip, Solu-Medrol taper
as well as continuing doses of Unasyn and CellCept. A venous
ultrasound was performed, which showed excellent flow in the
portal arterial and venous systems. She was slowly weaned
from the ventilator during postoperative day number zero.
She was also transfused 5 packs of platelets. She was
subsequently extubated later on postoperative day zero and
tolerated her extubation well. On postoperative day number
one she was started on total parenteral nutrition and had a
continuing insulin drip at 17 units per hour. She was
continuing on CellCept [**Pager number **] mg b.i.d. and she was started on
Cyclosporin 100 mg b.i.d. as well as continuation of her
Solu-Medrol taper. Her platelet count at this time was up to
111,000. Her INR was 1.4. Her ALT and AST were 383 and 323
with an alkaline phosphatase of 98 and a total bilirubin of
4.9. At this time her creatinine was 2.6. She was awake,
alert and doing quite well clinically.
Late on postoperative day number one she was deemed stable
and ready for transfer to the floor. Once on the floor on
postoperative day number two she continued to require an
insulin drip for proper control of her blood glucose,
however, at this time her home doses of Humalog were
reinstated enabling a decrease in her insulin drip to 3 units
per hour. Her creatinine at this time was 3.0. Her AST and
ALT began to decrease, however, she did experience an
increase in her total bilirubin to 6.9 at this time. Due to
this renal function her Cyclosporin dose was decreased to 50
mg b.i.d. She continued on her Solu-Medrol taper as well as
her same dose of CellCept. Secondary to the increase in
total bilirubin, she underwent a repeat ultrasound of her
liver, which again showed normal hepatic portal and arterial
and venous flow. She continued to improve throughout the
rest of her hospital course. By postoperative day number
four she no longer required an insulin drip and was now being
treated with her home doses of Humalog. Her Cyclosporin at
this time continued at 50 mg b.i.d. with a continuing
Solu-Medrol taper and CellCept at 1000 mg b.i.d. Her po
intake continued to improve, as did her urine output. Total
parenteral nutrition was discontinued on postoperative day
number five. It was felt at this time that the patient's
oral intake was adequate to meet her nutritional needs. Her
liver function tests continued to steadily improve and by
postoperative day number five the total bilirubin was down to
1.9 with an ALT of 74 and an AST of 19. Her creatinine also
began to improve at this time decreasing to 2.9. She
continued to improve in terms of mobility getting out of bed
multiple times per day and ambulating with assistance. Her
[**First Name8 (NamePattern2) 1661**] [**Last Name (NamePattern1) 1662**] drains were subsequently discontinued due to
decreasing output.
By postoperative day number eight she was deemed stable and
ready for discharge from the hospital. It was felt at this
time she would benefit from additional time in a acute
rehabilitation facility to further increase her strength and
mobility and improve her nutritional status. On the day of
discharge her creatinine had decreased to 2.4 and her total
bilirubin to 1.5 with a stable hematocrit and platelet count.
She had remained afebrile throughout her postoperative
course and quite alert and oriented.
DISPOSITION: To acute care rehabilitation facility.
DIET: Consistent carbohydrate diabetic diet with Nepro shake
supplementation with breakfast, lunch and dinner.
MEDICATIONS ON DISCHARGE:
1. Fluconazole 200 mg once per day.
2. Bactrim single strength one tablet once per day.
3. Protonix 40 mg once per day.
4. Prednisone 15 mg once per day.
5. CellCept [**Pager number **] mg twice a day.
6. Neoral 50 mg twice a day.
7. Levothyroxine 75 mg once per day.
8. Valcyte 450 mg every other day.
9. Lasix 20 mg once per day.
10. Colace 100 mg twice a day.
11. Humalog 75/25 30 units subQ each morning and 24 units
subQ each evening with dinner.
12. Oxycodone 1.25 mg q 6 hours as needed for pain.
ACTIVITY: As tolerated.
FOLLOW UP: There is a clinic appointment with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on [**2191-2-16**] at 11:30 in the morning. Follow up
has been detailed to the patient with a schedule from the
Transplant Center at [**Hospital1 69**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Name8 (MD) 12273**]
MEDQUIST36
D: [**2191-2-10**] 11:10
T: [**2191-2-10**] 11:16
JOB#: [**Job Number 12274**]
|
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] |
Admission Date: [**2154-5-29**] Discharge Date: [**2154-6-1**]
Date of Birth: [**2106-5-20**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Motorcycle accident
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient was involved in a high speed helmeted motor cycle
accident sustaining a splenic laceration, rib fractures, and a
concussion.
Past Medical History:
gout
Social History:
married
Family History:
non contributory
Physical Exam:
HR 90 BP: 172/89 RR20 O2sat: 100%
comfortable
normocephalic, atraumatic
oropharynx within normal limits.
Lungs clear to ausculation bilaterally
extremities without clubbing cyanosis or edema
Neuro: CN II-XII intact, speech fluent, mild confusion and
amnesia RE accident
Pertinent Results:
[**2154-5-29**] 09:15PM FIBRINOGE-428*
[**2154-5-29**] 09:15PM PT-14.3* PTT-23.4 INR(PT)-1.2*
[**2154-5-29**] 09:15PM PLT COUNT-278
[**2154-5-29**] 09:15PM NEUTS-89.2* LYMPHS-7.9* MONOS-2.6 EOS-0.1
BASOS-0.2
[**2154-5-29**] 09:15PM WBC-18.1* RBC-5.66 HGB-15.0 HCT-44.5 MCV-79*
MCH-26.5* MCHC-33.7 RDW-12.7
[**2154-5-29**] 09:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2154-5-29**] 09:15PM LIPASE-35
[**2154-5-29**] 09:15PM estGFR-Using this
[**2154-5-29**] 09:15PM GLUCOSE-130* UREA N-18 CREAT-1.2 SODIUM-139
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
[**2154-5-29**] 09:27PM GLUCOSE-128* LACTATE-1.8 NA+-143 K+-4.5
CL--99* TCO2-27
Brief Hospital Course:
Admitted to Trauma SICU following a helmeted high speed MVC with
a splenic laceration and fracture of his left [**7-19**] ribs.
Overnight his hematocrit was checked and remained stable. On HD
2 his foley was discontinued and he was transferred to the
floor. On the floor, his diet was advanced to regular. He was
encouraged to ambulate. He was given an oral pain regimen. He
developed some acute Left ankle/foot pain. A plain film was
ordered and showed no acute fracture. On further questioning the
patient admitted to a history of gout. A physical therapy
consult was obtained and the patient was given a walker to
faciliate ambulation. He was also started on Colchicine with
improvment in his pain. On HD 3, the patient was doing very
well. His pain was controlled, his HCT was stable, he was
tolerating a regular diet and he was eager to be discharged to
home.
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while using narcotics for pain control to
help prevent constipation.
Disp:*60 Capsule(s)* Refills:*0*
3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO every four
(4) hours: stop taking if you develop nausea/vomiting, or
diarrhea.
Disp:*7 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
left 7th and 10th rib fracture
grade III splenic laceration
Discharge Condition:
hemodynamically stable, tolerating oral intake, voiding without
issue, pain controlled with oral regimen
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ([**10-24**] lbs) until your follow up appointment.
* Any other symptoms that are concerning to you
Restrictions:
-do not take aspirin, naproxen, ibuprofen, or other
non-steroidal anti-inflammatory medications as these can
increase your risk of bleeding
-do not participate in contact sports or any activity that may
subject you to abdominal trauma until cleared by your surgeon
-use a walker for ambulation as needed.
Followup Instructions:
Please call the Trauma clinic at ([**Telephone/Fax (1) 376**] to schedule a
followup appointment in [**1-11**] weeks
Completed by:[**2154-6-9**]
|
[
"25000",
"4019"
] |
Admission Date: [**2121-3-31**] Discharge Date:
Date of Birth: [**2121-3-31**] Sex: F
Service: Neonatology
HISTORY: Baby girl [**Known lastname **] is a former 32 and [**6-17**] week female
admitted with respiratory distress and issues of prematurity.
The infant was born to a 33-year-old G2/P1 mother. [**Name (NI) 37516**] of [**2121-5-20**]. Hepatitis B negative, RPR nonreactive, rubella
immune, B positive, antibody negative. mother was a 1 pack per
day smoker.
PRENATAL COURSE: Significant for preterm labor with rupture
of membranes on [**3-28**]. Did receive 1 dose of betamethasone
on [**3-31**] at 3:00 p.m. On erythromycin and ampicillin since
[**3-31**] at 1500 hours. Mother had increased WBC on day of
delivery to 17 and concern for chorioamnionitis; thus decision to
deliver. Of note, biophysical profile on the day of delivery
was [**6-18**], minus 2 for decreased amniotic fluid.
GBS negative. No maternal fever.
PAST OBSTETRICAL HISTORY: Prior C-section, full term,
breech. Mother had Bell palsy during the last few weeks of
that pregnancy.
This infant was born by cesarean section on [**3-31**] at 20:19
hours. Apgar's of 8 at 1 minute, 9 at 5 minutes. Some facial
cyanosis noted that responded to O2. Brought to the newborn
intensive care unit, receiving oxygen with some grunting and
increased work of breathing, was placed on CPAP.
PHYSICAL EXAMINATION ON ADMISSION: Some facial bruising.
Anterior fontanel soft and flat. Normal S1/S2. No murmur.
Breath sounds coarse bilaterally with mild-to-moderate
intercostal/subcostal retractions. Abdomen soft, nontender,
and nondistended. Extremities well perfused. Tone appropriate
for gestational age. Spine intact. Hips stable. Normal female
genitalia.
REVIEW OF HOSPITAL COURSE BY SYSTEMS: RESPIRATORY: Baby was
placed on continuous positive airway pressure 6 cm, receiving
room air with a respiratory rate of 30s to 70s. At
approximately 24 hours of age, infant was transitioned to room
air. Has remained in room air with no further respiratory
distress.
Baby has had an occasional apnea and bradycardia. Is not
requiring any methylxanthine treatment. Would continue to
monitor for apnea and bradycardia of prematurity.
CARDIOVASCULAR: Baseline heart rate 120s to 160s with
systolic blood pressures 60s to 70s, diastolic's 30s to 40s,
mean's in the 40s to 50s. No murmur. Cardiovascularly stable.
FLUIDS, ELECTROLYTES AND NUTRITION: Baby initially was NPO
with a peripheral IV fluid of D10W. Enteral feedings
introduced at approximately 24 hours of age once the
respiratory status stabilized. Baby advanced to full enteral
feedings without any issues. She is currently feeding 150
mL/kg/day of breast milk 20 with a plan to increase caloric
density, follow growth and weaning according to growth
parameters. Baby is voiding and stooling without issue. Heme-
negative stools.
Lytes at 24 hours; sodium 132, potassium 5.9 (hemolyzed),
chloride 99, and bicarbonate 22. On day of life 3; sodium
149, potassium 5.8, chloride 119, CO2 of 20. At that time
total fluids were increased from 80 to 100 mL/kg/day, and no
further electrolytes have been indicated.
GI: Peak bilirubin was on day of life 3; 7.8/0.3/7.5. Baby
was under phototherapy. On day of life 5, [**4-5**], bilirubin
was 8.2/0.3/7.9. Phototherapy was discontinued on [**4-6**]
with a plan to check a rebound on [**4-7**].
INFECTIOUS DISEASE: Because of initial presentation and
maternal history, a CBC was sent at the time of delivery;
white count of 16.4, 30 polys, 0 bands, platelet count
195,000, and hematocrit of 59. The baby also had a blood
culture sent at that time, and was started on ampicillin
and gentamicin. At 48 hours the blood cultures were negative.
Baby was clinically well, and antibiotics were discontinued.
There have been no further issues with infection.
NEUROLOGY: Because of gestational age of greater than 32
weeks a head ultrasound or further scanning is not indicated.
Baby is clinically appropriate for gestational age.
SENSORY: Audiology screening has not been done at time of
transfer. Would recommend screen prior to discharge.
OPHTHALMOLOGY: Exam not indicated based on her gestational
age of greater than 32 weeks.
PSYCHOSOCIAL: Parents look forward to [**Known lastname **] [**Last Name (NamePattern1) **]
transferring closer to home. Have had difficulty visiting in
[**Location (un) 86**] and are aware of the transfer.
PRIMARY PEDIATRICIAN: [**Hospital **] Pediatrics at [**Hospital3 **].
CARE RECOMMENDATIONS:
1. Continue 150 mL/kg/day, advance calories as tolerated and
indicated based on growth. Baby is requiring some gavage
feedings. Encourage oral feedings.
2. Medications: None at time of transfer.
3. Car seat position screening will be needed prior to discharge
home .
4. State newborn screen: Initial screen was sent on [**4-3**];
results are pending, would continue per protocol with a
repeat screen to be sent on day of life 14.
IMMUNIZATIONS RECEIVED: None at the time of transfer.
IMMUNIZATIONS RECOMMENDED: Synagis RSV prophylaxis should be
considered from [**Month (only) **] through [**Month (only) 958**] for infants who meet
any of the following 3 criteria: (1) born at less than 32
weeks; (2) born between 32 and 35 weeks with 2 of the
following: Daycare during RSV season, a smoker in the
household, neuromuscular disease, airway abnormalities or
school-age siblings; or (3) with chronic lung disease.
Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age and for the first 24 months of the child's life
immunization against influenza is recommended for household
contacts and out of home caregivers.
FOLLOWUP: Appointment with primary care pediatrician per
routine.
DISCHARGE DIAGNOSES: Former 32 and [**6-17**] week premature
female; status post respiratory distress, probably
transitional tachypnea of a newborn, status post rule out
sepsis with antibiotics, apnea and bradycardia of
prematurity, hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2121-4-6**] 10:08:08
T: [**2121-4-6**] 11:01:49
Job#: [**Job Number 61310**]
|
[
"7742",
"V290"
] |
Admission Date: [**2182-3-3**] Discharge Date: [**2182-3-13**]
Date of Birth: [**2134-1-2**] Sex: F
Service: [**Doctor Last Name **]-MED
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a 48 year old
female with a 16 year history of HIV; recent CD4 count of 2
and viral load of 34,000, who was admitted on [**3-3**], with a
diagnosis of a subcapsular renal hematoma. Mrs. [**Known lastname **] has
developed an acidosis and hypokalemia over the past several
months and had a rising BUN and creatinine. On [**2-27**], she
had a left renal biopsy which was apparently tolerated
without incident. She was discharged home and did well until
[**3-3**], when she returned to the Emergency Department with
left lower quadrant pain, nausea and vomiting.
A CT scan in the Emergency Room revealed a left renal
subcapsular hematoma and labs revealed a hematocrit of 18.
She was transfused two units of packed red blood cells and
given two units of fresh frozen plasma and transferred to the
Intensive Care Unit.
In the Intensive Care Unit, her hematocrit rose to 27 and she
was stable overnight. On the morning of [**3-4**], she was
called out to the [**Location (un) 2655**] Medicine Firm where we took care
of her from that point on.
PAST MEDICAL HISTORY:
1. Human Immunodeficiency Virus for 16 years. She has had
both fungal and viral infections; a fungal infection of her
esophagus, Pneumocystis carinii pneumonia about four years
ago and shingles times two.
2. Anemia believed to be multi-factorial in nature due to
both HIV infection as well as anti-viral medications. Iron
studies in [**5-/2181**], suggested iron deficiency is not a
significant cause of this anemia, although the patient does
state that her menstrual periods sometimes have a heavy flow.
The patient's erythropoietin level on [**12/2181**] was high,
reducing the possibility of a renal etiology. Baseline
creatinine was 2.7 on the day of renal biopsy.
3. History of hypertension.
ALLERGIES: Allergies include sulfa drugs.
MEDICATIONS ON TRANSFER OUT OF THE UNIT:
[**Unit Number **]. Lamivudine 150 mg p.o. twice a day.
2. Ritonavir/Lopinovir combination, three capsules p.o.
twice a day.
3. Tenofivir 300 mg p.o. q. day.
4. Pantoprazole 400 mg p.o. q. 24.
5. Fexocenidine 60 mg p.o. twice a day.
6. Sirtoline HCl 100 mg p.o. q. day.
7. Hydromorphone 1 to 2 mg intravenously q. three to four
hours p.r.n. flank pain.
8. Dapsone 100 mg p.o. q. day.
9. Acetaminophen 325 to 650 mg p.o. q. six hours p.r.n.
SOCIAL HISTORY: The patient lives with her two sons. She
does not work. She denies tobacco, alcohol, or intravenous
drug abuse history. She reports she contracted HIV through
sexual contact.
FAMILY HISTORY: Father died of brain aneurysm. Mother is
alive with chronic obstructive pulmonary disease.
PHYSICAL EXAMINATION: On admission to the floor, vital
signs were temperature 100.1 F.; pulse 83; blood pressure
100/82; respiratory rate 18; O2 93% on room air. Lungs clear
to auscultation bilaterally. Cardiovascular examination is
regular rate and rhythm. No murmurs, rubs or gallops.
Abdomen is soft, nondistended, left lower quadrant
tenderness. No obvious hepatosplenomegaly. Lower
extremities with no edema. Skin with no lesions.
LABORATORY: From the Unit, included a white blood cell count
of 11.2, hematocrit 27.4, platelets of 154, INR of 1.2.
Urinalysis showing greater than 300 mg per dl of protein.
Glucose 181, BUN 34, creatinine 2.4. Sodium 140, potassium
3.0, chloride 109, bicarbonate 15.
HOSPITAL COURSE:
1. Renal hematoma: Urology saw the patient when she was in
the Medical Intensive Care Unit on [**3-3**], and did not
recommend any surgical intervention. Her hematocrit bumped
well with blood and it was determined that as long as the
patient's hematocrit remained stable, they could avoid any
invasive procedures. They has also noted that before they
would proceed to surgery they would attempt an Interventional
Radiology procedure.
In any event, the patient continued to do well, was
transferred out to the floor. Her hematocrit was checked
twice a day. She required one unit of blood two days after
being called out the floor, but other than that, remained
stable. She had a renal ultrasound repeated on [**2182-3-7**],
which showed continued presence of the hematoma but no
significant change in size, and her hematocrit remained
stable. At the time of discharge, her hematocrit was 29.3,
which we believed is near her baseline, which actually is
27.0.
2. Fungal esophagitis: The patient had been on [**Last Name (LF) 108861**],
[**First Name3 (LF) **] experimental Conazol medication until approximately one
month prior to admission. This was for treatment of biopsy
proven fungal esophagitis. The patient's medication was
stopped because her QT began to get prolonged which is a
known complication of the drug. She had been on no treatment
since then and in-house complained of esophageal pain.
Because of this, the Infectious Disease Team was consulted
and recommended Nystatin swish and swallow for the time being
and a repeat esophagogastroduodenoscopy to document that, in
fact, she did have continued fungal esophagitis and that she
did not develop a new cause of esophagitis such as CMV or
HIV.
The patient, however, refused to have an
esophagogastroduodenoscopy in-house saying that she couldn't
do it at the present time because she felt too weak and not
up to it. She did request that she have it as an outpatient.
This was discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6861**], the Gastrointestinal
fellow who had performed her previous EGD. He said that the
patient could have this following discharge as an outpatient.
The patient was agreeable to this. At the time of her
discharge, her esophageal pain was still present but stable.
3. HIV: The patient was continued on all her HIV
medications that she came in on.
4. Infectious Disease: The patient continued to have fevers
throughout her course here as high as 102.0 F., generally
spiking once to twice a day. Blood cultures and urine
cultures were sent several times and failed to prove
anything. It was believed that these fevers were largely due
to her retroperitoneal hematoma which can cause this.
However, she did have one urinalysis come back positive and
ultimately grew out Enterococcus.
Because of this, she was put on Amoxicillin which she will be
discharged home on to complete a seven-day course.
Additional positive blood cultures results were femoral line
catheter tip that was removed and grew out coagulase negative
Staphylococcus. This was believed to be a contaminant and
the line was removed, so it was not believed to be a problem.
5. Hypertension: The patient was continued on her Lopressor
without incident.
6. Renal: The renal biopsy results were still being
determined at the time of her discharge. However,
preliminary results per the Renal Team showed a
micro-angiopathic pattern which was unexpected since the
leading diagnosis to have the biopsy was HIV nephropathy.
The Renal Team had plans to discuss this with
Hematology/Oncology Service and would follow-up with the
patient to discuss results and potential treatment.
7. Pain: The patient's left lower quadrant pain was still
present at discharge, however, had improved. We will
discharge her on p.r.n. Dilaudid for pain control.
DISPOSITION: At the time of this dictation, the patient was
planned to be discharged the following morning of [**3-9**],
to home. She does not require any services per her
attending, and will follow-up with her attending next week.
She already has an appointment.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE INSTRUCTIONS:
1. Follow-up will be with Dr. [**Last Name (STitle) 9751**].
DISCHARGE DIAGNOSES:
1. Retroperitoneal subcapsular left renal hematoma secondary
to renal biopsy.
2. Human Immunodeficiency Virus.
3. Fungal esophagitis.
4. Enterococcus urinary tract infection.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
1. Amoxicillin 500 mg p.o. twice a day times two more days
following discharge.
2. Nystatin Swish and Swallow.
3. Tenofivir 300 mg p.o. q. day.
4. Colectra 3 capsules p.o. twice a day.
5. Lamivudine 150 mg p.o. q. day.
6. Dilaudid 2 to 4 mg p.o. q. four to six hours p.r.n.
7. Lopressor 25 mg p.o. twice a day.
8. Dapsone 100 mg p.o. q. day.
9. Zoloft 100 mg p.o. q. day.
10. [**Doctor First Name **] 60 mg p.o. q. day.
11. Protonix 40 mg p.o. q. day.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 108862**], M.D. [**MD Number(1) 108863**]
Dictated By:[**Last Name (NamePattern1) 1213**]
MEDQUIST36
D: [**2182-3-8**] 14:02
T: [**2182-3-9**] 17:52
JOB#: [**Job Number 108864**]
|
[
"5990",
"4019"
] |
Admission Date: [**2110-1-10**] Discharge Date: [**2110-2-5**]
Date of Birth: [**2036-5-26**] Sex: M
Service: HEPATOBILIARY (BLUE) SURGERY
ADMISSION DIAGNOSES:
1. Cholangiocarcinoma.
2. History of squamous cell carcinoma of the lip.
3. Hypercholesterolemia.
4. Questionable history of prior inferior myocardial
infarction.
DISCHARGE DIAGNOSES:
1. Cholangiocarcinoma status post cholecystectomy with
common duct excision with left hepatic lobectomy and pylorus
sparing Whipple, status post reexploration for bleeding.
2. History of squamous cell carcinoma of the lip.
3. Hypercholesterolemia.
4. Questionable history of prior inferior myocardial
infarction.
5. Blood loss anemia.
6. Bacteremia.
ADMISSION HISTORY AND PHYSICAL: Mr. [**Known lastname 53382**] is a 73 year-old
male who initially presented to an outside hospital with a
painless jaundice and a CA199 of 665 at which time he
underwent an endoscopic retrograde cholangiopancreatography,
which was thought to be consistent with a ________ tumor and
had a sphincterotomy and plastic stent placed with brushings
at the time, which demonstrated atypical cells consistent
with cholangiocarcinoma. He underwent CT scan, which did not
show visible lesions and subsequently underwent removal of
the plastic stent and the PTC. Given his diagnosis he was
referred for surgical management to Dr. [**Last Name (STitle) **] of the
Hepatobiliary Service. At the time of his admission and
prior to the surgery his total bilirubin was 2.3 with a
direct of 1.5 and an indirect of 1.8, alkaline phosphatase
263 and his ALT and AST were 55 and 56 respectively.
HOSPITAL COURSE: The patient was admitted on [**2109-1-10**] and on that same day underwent cholecystectomy with a
common duct excision and a left hepatic lobectomy and a
pylorus sparing Whipple. Intraoperatively there was noted to
be a great deal of inflammation desmol plastic reaction in
the porta hepatis and a mass at the confluence of the right
and left hepatic ducts. There was no note of excessive
intraoperative blood loss and the patient tolerated the
procedure well and was taken to the Post Anesthesia Care Unit
in stable condition postoperatively from which he was
transferred to the Intensive Care Unit. In terms of his
hospital course from a neurological point of view the patient
had no significant issues. His pain was initially controlled
with an epidural, which was managed by the Acute Pain
Service. This was weaned secondary to episodes of
hypotension after which time narcotics such as morphine were
used prn for sedation and pain control. From a respiratory
standpoint the patient remained intubated postoperatively for
respiratory support, but the patient was planned to wean from
to extubation on postoperative day five, but remained
extubated secondary to complication of bleeding for which he
was taken back to the Operating Room. He was subsequently
extubated on postoperative day three after the second
procedure. He did notably develop some pleural effusions
postoperatively, but these were improving prior to discharge.
From a cardiac standpoint the patient did fairly well and had
no noted events of ischemia. From a gastrointestinal
standpoint the patient's course was relatively complicated.
The final pathology from the surgery did reveal that he did
have metastatic adenocarcinoma involving the lymph nodes and
biliary ducts as noted. Given the extent of the surgery the
patient did have drains, which remained postoperatively for
bile drainage. The patient's Intensive Care Unit stay was
notable for aggressive diuresis with Lasix secondary to large
amounts of fluid he received in the immediate perioperative
period. Electrolytes were repleted as needed. From a
nutrition standpoint the patient was started on total
parenteral nutrition in the immediate postoperative period.
By the time of discharge his total parenteral nutrition was
discontinued two days prior to discharge as he had adequate
po intake and regular diet and Boost supplement shakes. From
a renal standpoint the patient's initial creatinine remained
around 1.0 with slight variations, but was noted during the
last week of his hospitalization to be slightly elevated and
prior to discharge his creatinine was 1.4 with a BUN of 40.
There were no overt episodes of acute renal failure, although
he did have some oliguria in the Intensive Care Unit for
which he required albumin. Notably the patient did have a G
tube cholangiogram to evaluate for a leak via the T tube.
There was no evidence of leak and the intrahepatic right bile
duct looked normal.
Hematologically as noted above the patient did have an
episode of hypotension postoperatively along with a
significant amount of a sanguinous output from his JP drain
at which time he was taken back to the Operating Room and
reexplored and found to have a bleeding vessel, which was
then suture ligated. He was transfused as needed and by the
time of discharge his hematocrit had been stable between 34
and 35. From an infectious disease standpoint the patient
was given broad spectrum antibiotic coverage postoperatively
with Unasyn. In terms of his culture data his peritoneal
fluid did grow out some [**Female First Name (un) **], otherwise he did have one
set of blood cultures, which showed coag negative staph.
Biliary fluid did grow E-coli. Given these culture findings
he was treated with Vanco, Zosyn and Ambazone starting on
postoperative days six and two. After a two week course of
the previously mentioned broad spectrum antibiotics he was
switched over to Ciprofloxacin on postoperative days 21 and
17 for cholangitis prophylaxis. Blood cultures drawn prior
to his discharge were all negative.
In terms of laboratories prior to discharge his white blood
cell count was 19.2 and was somewhat elevated, but the
patient had been afebrile and no focal source of infection
was noted. His hematocrit was 35. His platelet count was
180, INR 1.3 with a PT of 138. Otherwise his BUN and
creatinine were 40 and 1.4, K was 4.2. In terms of liver
function tests his ALT and AST were 136 and 186 with an
alkaline phosphatase of 237 and a total bilirubin of 10.0.
His albumin was 2.8.
DISCHARGE MEDICATIONS:
1. Ciprofloxacin 500 mg po q.d. until follow up in one week.
2. Reglan 10 mg po q.i.d. a.c.h.s.
3. Protonix 40 mg po q.d.
4. Pancrease two caplets po t.i.d. with meals.
5. Boost shakes two po b.i.d.
He was discharged with VNA nursing for daily weights, Boost
shakes and he would have repeat laboratory testing and follow
up in the [**Hospital 52796**] Clinic in one week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,PH.D.[**MD Number(3) 48821**]
Dictated By:[**Last Name (NamePattern1) 13262**]
MEDQUIST36
D: [**2110-2-5**] 11:17
T: [**2110-2-5**] 11:25
JOB#: [**Job Number 53383**]
|
[
"2851",
"5119",
"2762"
] |
Admission Date: [**2155-1-25**] Discharge Date: [**2155-1-25**]
Service: MEDICINE
Allergies:
Fosamax / Doxazosin
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
Found unresponsive
Major Surgical or Invasive Procedure:
Intubated
History of Present Illness:
Ms. [**Known lastname **] is an 82 yo female with AFib on coumadin who was found
in [**Hospital3 **] unresponsive. Of note, she
was seen in the ED on [**1-22**] after a recent trip and fall; head CT
was negative for acute bleed at that time and she was sent back
to the [**Hospital3 537**].
Past Medical History:
HTN
Hyperlipidemia
Atrial fibrillation
Hypothyroidism
Vascular dementia
h/o thrombophlebitis
Macular degeneration
Social History:
Lives at [**Hospital3 537**].
Family History:
NC
Physical Exam:
General Appearance: No acute distress
Eyes / Conjunctiva: Laterally roving eye movments.
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
Cardiovascular: Irregularly irregular; no m/r/g/ apprecitaed
Respiratory / Chest: CTA b/l, no wheezes, no crackles
Abdominal: Soft, Bowel sounds present, Not distended
Skin: no rash
Neurologic: fully unrepsonsive to painful stimuli while off
sedation (propofol);
upgoing Babinksi's b/l; no corneal or gag refluxes; decerebrate
posturing; no withdrawal to pain
Pertinent Results:
ADMISSION LBAS:
[**2155-1-25**] 07:15AM BLOOD WBC-12.6* RBC-4.52 Hgb-13.8 Hct-40.0
MCV-89 MCH-30.5 MCHC-34.5 RDW-13.7 Plt Ct-194
[**2155-1-25**] 07:15AM BLOOD Neuts-73* Bands-4 Lymphs-9* Monos-12*
Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2155-1-25**] 07:15AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Tear
Dr[**Last Name (STitle) **]1+
[**2155-1-25**] 07:15AM BLOOD PT-16.0* PTT-24.0 INR(PT)-1.4*
[**2155-1-25**] 07:15AM BLOOD Glucose-197* UreaN-19 Creat-1.0 Na-137
K-3.6 Cl-98 HCO3-25 AnGap-18
[**2155-1-25**] 07:15AM BLOOD ALT-22 AST-35 CK(CPK)-69 AlkPhos-65
TotBili-1.0
[**2155-1-25**] 07:15AM BLOOD Calcium-9.5 Phos-2.1* Mg-1.6
[**2155-1-25**] HEAD CT:
1. Massive subarachnoid hemorrhage with massive intraventricular
extension
and marked hydrocephalus.
2. Brainstem edema and possible infarction.
3. Since the hemorrhage extends into the imaged upper thecal
sac, spine
imaging should be contemplated, if allowed by the patient's
condition.
Brief Hospital Course:
In the ED, she was intubated as she was full code per the ED's
understanding. Exam showed that pupils were fixed and dilated;
she had no gag or corneal reflexes. CT head without contrast
showed extensive SAH with intravenricular extension, marked
hydrocephalus. Neurosurgery was consulted and deferred
intervention as they felt the case was futile. Neurology
agreed. She received vitamin K and was placed on a propofol
drip until her family could arrive for extubation.
On arrival to the MICU, propofol sedation was weaned without
improvement in neurological status. Pateint was euthermic. She
had upgoing Babinksi's b/l; no corneal or gag reflexes;
decerebrate posturing; no withdrawal to pain.
The family decided to withdrawal care, including extubation, and
make the patient CMO with morphine drip within two hours of
arrival to the MICU. She passed several hours later with family
by her bedside.
Medications on Admission:
Pertinent meds: coumadin
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
Subarachnoid hemorrheage reuslting in brain death
Discharge Condition:
Expired shortly after admission
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"42731",
"4019",
"2724",
"2449"
] |
Admission Date: [**2199-1-23**] Discharge Date: [**2199-1-28**]
Date of Birth: [**2132-2-27**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Chlorpromazine / Latex
Attending:[**First Name3 (LF) 8115**]
Chief Complaint:
Fever, Gram-negative rod bacteremia, metastatic gallbladder CA.
Major Surgical or Invasive Procedure:
Endoscopic retrograde cholangiopancreatography
History of Present Illness:
Mr. [**Known lastname 11679**] is a 66-year-old man with metastatic gallbladder
cancer, last chemo FOLFIRI on [**2199-1-16**], admitted for fever and
GNR bacteremia. He called his oncologist on [**2199-1-22**] with fevers
and was sent to [**Hospital3 10310**] hospital for blood count check.
At that time he was not neutropenic and initial work-up was
unremarkable. However, today his blood culture came back
positive with gram negative rods. He was asked to come to the
[**Hospital1 18**] ED.
.
In the ED, T 98, HR 110, BP 96/59, RR 20, 98% RA. U/a showed no
pyuria. WBC 3.8 with 91% polys. CXR revealed a small-to-moderate
left pleural effusion with overlying atelectasis. He was given
vancomycin, gentamicin, levofloxacin, and meropenem.
.
ROS: He denies sweats, nausea, vomiting, headache, chest pain,
shortness of breath, cough, back pain, constipation,
hematochezia, hematuria, other urinary symptoms, or rash. All
other ROS were negative.
Past Medical History:
ONCOLOGIC HISTORY
Gallbladder Ca - diagnosed in [**1-/2198**] on cholecystectomy w path
demonstrating adenocarcinoma poorly differentiated, w liver
invasion, extracapsular extension, and positive LN, s/p ERCP
[**1-/2198**] with stenting of the CBD and CHD, s/p C6 gem/cis, XRT L
rib lesion, s/p FLOX, s/p C3 FOLFIRI (last dose 2/16).
.
MEDICAL HISTORY
Hypercholesterolemia
Bilateral knee replacements in [**2193**]
CCY and gallbladder fosa dissection [**2198-1-22**].
Social History:
Lives with wife at home. Denies any smoking history and drinks
alcohol occasionally.
Family History:
Mother who died at age [**Age over 90 **] of Alzheimer's disease. His father
died at age [**Age over 90 **],
also of Alzheimer's disease. His grandparents died at a young
age of unknown causes.
Physical Exam:
VS: Tmax 98.7F, BP 108/66, HR 68, RR 16, O2 Sat 96% RA.
GEN: A&O, no acute signs of distress.
HEENT: Sclerae non-icteric, o/p clear, mmm, mild
mucositis/thrush.
Neck: Supple, no thyromegaly.
Lymph nodes: No cervical, supraclavicular, or inguinal LAD.
CV: S1S2, RRR, no murmurs, rubs or gallops.
RESP: Good air movement bilaterally, no rhonchi or wheezing.
ABD: Soft, NT, ND, no HSM.
EXTR: No edema.
DERM: Psoriatic lesion on LE and temples.
Neuro: Non-focal.
PSYCH: Appropriate and calm.
Pertinent Results:
[**2199-1-24**] CT abd/pelvis
1. Unchanged minimal central intrahepatic biliary prominence.
2. CBD stent in unchanged position with persistent soft tissue
in porta hepatis likely represent local invasion gallbladder
carcinoma with unchanged diffuse peritoneal carcinomatosis.
3. Bilateral simple pleural effusions.
[**2199-1-25**] ERCP Report
Normal major papilla with previous sphincterotomy noted.
Cannulation of the biliary duct was successful and deep using a
free-hand technique. Contrast medium was injected. Previous
metal stent noted in CBD. Intrahepatic ducts were normal,however
filling of CBD in proximal area was incomplete indicating
blockage. CBD was sweeped with a balloon catheter and sludge and
debris was removed. As there was resistance to balloon pull at
ampulla, sphincterotomy was extended in the 12 o'clock position
using a sphincterotome over an existing guidewire. Duct was
cleared of debris with balloon sweeps. Excellent drainage of
bile and contrast noted.
ADMISSION LABS:
[**2199-1-23**] 05:24PM LACTATE-1.2
[**2199-1-23**] 04:20PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.026
[**2199-1-23**] 04:20PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-150
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-8* PH-6.5 LEUK-NEG
[**2199-1-23**] 04:20PM URINE RBC-[**5-10**]* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-[**10-20**]
[**2199-1-23**] 04:20PM URINE MUCOUS-MOD
[**2199-1-23**] 03:30PM GLUCOSE-137* UREA N-22* CREAT-0.9 SODIUM-129*
POTASSIUM-3.8 CHLORIDE-95* TOTAL CO2-26 ANION GAP-12
[**2199-1-23**] 03:30PM estGFR-Using this
[**2199-1-23**] 03:30PM ALT(SGPT)-45* AST(SGOT)-37 LD(LDH)-303* ALK
PHOS-318* TOT BILI-0.9
[**2199-1-23**] 03:30PM LIPASE-32
[**2199-1-23**] 03:30PM WBC-3.8* RBC-2.83* HGB-10.1* HCT-29.3*
MCV-104* MCH-35.8* MCHC-34.6 RDW-15.0
[**2199-1-23**] 03:30PM NEUTS-90.7* LYMPHS-3.5* MONOS-5.3 EOS-0.3
BASOS-0.2
[**2199-1-23**] 03:30PM PLT COUNT-134*
DISCHARGE LABS:
[**2199-1-28**] 06:00AM BLOOD WBC-3.4* RBC-2.51* Hgb-8.8* Hct-25.8*
MCV-103* MCH-35.0* MCHC-34.0 RDW-14.6 Plt Ct-154
[**2199-1-28**] 06:00AM BLOOD Glucose-101* UreaN-9 Creat-0.6 Na-137
K-3.7 Cl-102 HCO3-30 AnGap-9
[**2199-1-28**] 06:00AM BLOOD ALT-68* AST-64* AlkPhos-517* TotBili-1.3
Brief Hospital Course:
HOSPITAL COURSE
This is a 66yo M w/ h/o stage IV gallbladder ca diagnosed [**1-10**],
s/p FOLFIRI (last dose [**2199-1-16**]) p/w GNR bacteremia, now on
meropenem, ERCP demonstrating incomplete obstruction of CBD, now
s/p clearance of obstruction, remaining hemodynamically stable
and comfortable
.
ACTIVE
#. GNR sepsis: Patient was admitted with an OSH blood cx
reported as being postiive for w klebsiella (R to ampicillin),
with blood cultures positive here as well. No obvious source in
urine and lungs. The patient was started on meropenem. Likely
source was thought to be biliary obstruction given history of
gallbladder ca. On ERCP partial obstruction was visualized and
cleared. The patient's transaminases came down in the post
procedural period, and his bilirubinemia normalized. His
meropenem was narrowed to oral ciprofloxacin on [**1-28**]. He will
receive treatment for a total of 14 days beginning on [**1-24**].
.
# Stage IV gallbladder cancer: As above, it was thought
gallbladder was likely source for infection. Plans to initiate
continuous 5FU pump were deferred to outpatient setting.
.
INACTIVE
# GERD: Continued omeprazole.
Medications on Admission:
Baclofen 10mg PO q4hr for hiccups
Lorazepam 0.5-1mg PO q4-6hr prn nausea
Metoclopramide 10mg PO TID
Omeprazole 40mg PO daily
Ondansetron 4mg TID prn
Aspirin 81mg PO daily
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
3. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
4. Emend 125 mg Capsule Sig: One (1) Capsule PO days 1,2,3 of
chemo.
5. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
6. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
7. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for nausea.
8. oseltamivir 75 mg Capsule Sig: One (1) Capsule PO twice a
day.
9. Cipro 750 mg Tablet Sig: One (1) Tablet PO twice a day for 12
days.
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Obstructive Hyperbilirubinemia
Gallbladder CA
hypercholesterolemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 11679**],
You were admitted to [**Hospital1 18**] for the evaluation and treatment of
your fever. When you were admitted we found that there was
bacteria in your blood. We treated you with antibiotics and you
began to feel better. Because our laboratory examination showed
that your liver and bile system were likely blocked, we had you
undergo an ERCP procedure. During this procedure they were able
to relieve the blockage. You tolerated this procedure well with
no complications, and did well in the recovery period. You were
then deemed safe for discharge on oral antibiotic medicines.
Medications:
Added: ciprofloxacin
Changed: none
Removed: none
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2199-1-30**] at 8:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6198**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2199-1-30**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) 4908**] MD [**MD Number(2) 8116**]
|
[
"2761",
"5119",
"2720"
] |
Admission Date: [**2187-6-11**] Discharge Date: [**2187-7-13**]
Date of Birth: [**2111-10-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Anemia
Chronic Renal Insufficiency
Major Surgical or Invasive Procedure:
Tunneled cathether placement
Hemodialysis
CT Scan
MRI
History of Present Illness:
75 yoM w/ h/o CAD s/p CABG X 4, Type II DM, CRI presents from
[**Hospital1 **] with persistant anemia. Pt had prolonged admission
[**Date range (3) 21103**] following NSTEMI. Given 3 vessel disease on
cath, he underwent CABG X 4 [**2187-3-22**]. Post-op course c/b left
hemothorax, respiratory distress requiring re-intubation POD #9
followed by prolonged wean requiring trach/PEG [**2187-4-3**]. He was
diagnosed with VAP (Pseudomonas cepacia, MRSA), for which he was
treated with meropenem/vanco for 14 day course (completed [**5-14**]).
He was discharged to [**Hospital **] Rehab [**2187-5-11**]. He was weaned to a
trach mask by early [**5-29**]. On [**5-31**] a CXR (obtained due to
increased thick yellow secretions) showed moderate pulmonary
edema with bilateral pulmonary infiltrates. Sputum cx from [**5-31**]
grew Enterobacter cloacae, Paeruginsoa, and MRSA. He was covered
with Ceftaz/vanco starting [**6-4**] for presumed ventilator
associated pneumonia. On [**6-8**], RR was noted to be increased with
decreased O2 sats and he was placed back on vent (PS 15/5, FiO2
0.4, PEEP 5). His HCT decreased to 24 [**6-9**], for which he
received 2u PRBC with improvement of HCT to 31, followed by
decline to 29.6 today. Per NH records, he has had 3 transfusions
over the last 2-3 weeks (exact # unclear) and stools have been
brown gauiac positive. He was also noted to have increased tube
feed residuals, and vomited once today. He was transferred to
[**Hospital1 18**] today for further w/u of suspected GI bleed.
.
In the ED, T 97.5, p 58, bp 130/56, resp 18, 100% AC 550 x 16,
FiO2 0.5, PEEP 5. Lavage through PEG tube with BRB with mucus.
He received Protonix 40 mg IV X 1 and was transferred to MICU
for further management. Currently, the patient denies shortness
of breath, chest pain, nausea, abdominal pain. He has had
alternating constipation and diarrhea for the last several
weeks.
Past Medical History:
1. CAD: PTCA LAD ([**2180**]), NSTEMI ([**2-27**]), CATH ([**2187-3-19**])- LAD
90%, LCX 60%, RCA 100%, CABG X 4 ([**2187-3-22**]) LIMA -> LAD SVG ->
OM2 SVG -> PDA SVG -> Diag
- TTE 4/36/05 LVEF >55%, 1+ MR, impaired LV relaxation, apical
hypoK
2. CRI (CR 1.5-2.4)
3. DM II
4. CVA: Left sided weakness. Carotid US <40% stenosis bilateral
5. HTN
6. DEMENTIA (mild)
7. h/o VAP [**4-29**] with Pseudomonas cepacia, MRSA, s/p 14 days
vanco/meropenem.
8. s/p open trach/PEG [**2187-4-3**]
9. Right gluteal pressure sore
10. Anemia (baseline 26-31)
11. Arthritis
Social History:
Former judge in [**Country 532**]. Former EtOH (2 drinks/day), none for the
last 3 months. No tobacco or other drug use.
Family History:
N/C
Physical Exam:
PE: T 97.5, p 58, bp 130/56, resp 18 100%
AC 550 X 16, FiO2 0.5, PEEP 5
Gen: Elderly Russian male, alert, NAD
HEENT: PERRL, EOMI, anicteric, tracheostomy in place, neck
supple, no anterior cervical LAD, JVP ~10 cm
Cardiac: bradycardic, regular, II/VI SM at apex
Pulm: Coarse ronchi throughout. Decreased LS at bases
bilaterally with minimal crackles.
Abd: Distended, hypoactive BS, soft, NT
Ext: 1+ LE edema bilaterally, warm, 1+ DP bilaterally
Pertinent Results:
EKG: SB @ 56 bpm, 0.[**Street Address(2) 1755**] elevations V1, V2 (no sig change
from [**2187-4-13**])
RADIOLOGY Final Report
MRA BRAIN W/O CONTRAST [**2187-6-25**] 5:59 PM
MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST
Reason: evaluate for bleed/CVA/acute process
[**Hospital 93**] MEDICAL CONDITION:
75 year old man with vent-associated pneumonia, CRI on HD,
mental status changes
REASON FOR THIS EXAMINATION:
evaluate for bleed/CVA/acute process
INDICATION: 75-year old male with ventilation associate
pneumonia. Mental status change.
TECHNIQUE: Multiplanar T1 and T2-weighted images of the brain.
MR angiography with time-of-flight technique also performed.
Comparison is made with a prior head CT dated [**2187-6-22**].
FINDINGS: Note is made of mild brain atrophy with mildly
enlarged ventricles. Note is made of multiple areas of T2 high
signal intensities within the deep white matter, representing
chronic small vessel ischemia and old infarction. No evidence of
acute or hyperacute infarction noted on diffusion-weighted
images. No evidence of intracranial mass lesion noted. No mass
effect is seen. No susceptibility abnormality is seen.
On MR angiography, note is made of hypoplastic right vertebral
artery with minimal flow, with probable PICA termination.
Otherwise, no significant stenosis is seen. No evidence of
aneurysm.
IMPRESSION:
MRI: Multiple old infarctions and chronic small vessel ischemia.
No evidence of acute infarction.
MRA: Small right vertebral artery with probable PICA
termination. No evidence of aneurysm or significant stenosis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 7210**] [**Name (STitle) 7211**] [**Doctor Last Name 7205**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 21104**]
Approved: TUE [**2187-6-26**] 2:15 PM
The recording began at 9:30 on the morning of [**7-4**]. It
showed a low voltage [**3-30**] Hz slow background in all areas with
occasional
bursts of generalized slowing. There was marginally more focal
slowing
in the right anterior quadrant. Occasional right frontal sharp
waves
appeared less frequent than on the previous day's recording. The
recording did not change significantly over the day.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This EEG monitored cerebral function at the bedside
from
[**9-4**]. It showed an encephalopathic background
throughout.
There were occasional right frontal or anterior quadrant blunted
sharp
waves and additional slowing but no signs of ongoing seizures.
The
encephalopathy was the dominant feature, and it did not change
significantly over the course of the recording.
INTERPRETED BY: [**Last Name (LF) **],[**First Name3 (LF) **] W.
([**3-/2091**]U)
Brief Hospital Course:
A/P: 75 yoM w/ CRI, CAD s/p CABG X 4, trach/PEG for prolonged
ventilator wean presented with VAP and persistant anemia with
guaiac positive stool. Hospital course complicated by
deteriorating mental status exacerbated by hypoglycemic episode
[**2187-6-28**] with probable associated seizure activity. Also
complicated by pneumonia on [**2187-7-10**].
1) Altered mental status: Decline in mental status
deteriorating to persistent vegetative state. Multifactorial
cause including uremic encephalopathy, hypoglycemic episode on
[**2187-6-28**], seizure activity, generalized atrophy noted on MRI,
likely reflective of chronic multi-infarct small vessel disease.
Throughout the pt's admission, he became increasingly obtunded.
As compared with his baseling on admission, he became
increasingly unable to interact or communicate with either
hospital staff or his family and became almost completely
unresponsive. Initially, several etiologic factors were
suspected, chiefly toxic metabolic disease secondary to his
worsening renal function. Also seizure activity secondary to
prior CVA may have contributed to this, suggested by
epileptogenic foci seen on EEG (although no active seizure was
seen). CT studies revealed no new mass or bleed, MRI revealed
no new ischemic or vascular disease but did reveal chronic
atrophic changes.
The patient's mental status showed mild improvement with
hemodialysis. By the fourth round of hemodialysis the patient
appeared to be aware of other people in the room. On [**6-28**], per his family, the patient was attempting to mouth words.
Unfortunately, his mental status acutely declined the following
night, becoming again almost completely unresponsive. His blood
glucose levels was noted to have fallen from 100-150 level to
almost nil within a few hours. He was given an ampule of D50
for profound hypoglycemia, 1 mg Ativan IV for possible seizure
activity and underwent CT scan which ruled out any acute bleed
or mass effect. After multiple treatments of dextrose his
blood glucose returned to 120-130 range, pt was temporarily on a
dextrose intavenous drip as well. His doses of Humalog were
stopped as was his insulin sliding scale. Neurology and
Endocrine services were consulted. Neurology recommended
starting patient on phenytion. Endocrine advised that, in the
setting of his renal function deteriorating to end stage, the
kinetics of insulins (which are renally cleared) would be
altered unpredictably. In addition renal gluconeogenesis is
impaired. The patient likely suffered increased impairment in
renal clearance of insulin, as well as in renal gluconeogenesis
that night that led to his acute hypoglycemia. With guidance of
the Endocrine service we changed his insulin from Humalog to the
shorter acting NPH and aiming for glucose ranges in the 150.
It should be noted that the patients kidney function had
been end stage for almost two weeks, that he had been on the
humalog/RISS as well as been on continuous tube-feedings
throughout that time. After his episode of hypoglycemia, we
aggressively monitored his glucose levels and, with the help of
the endocrine service, adjusted his doses of NPH accordingly.
Several EEG's were performed. No active seizure activity was
seen but there were foci with eptileptogenic potential noted in
R frontal lobe. Dilantin dosages were also adjusted until
therapeutic levels could be achieved. This patient will likely
require Dilantin for the remainder of his days. The patient
remained in eu- or hyperglycemic ranges following the
hypoglycemic episode on the [**6-28**]//05 but did not show significant
improvement in mental status over the next 10 days. Neurology
felt the prognosis for improvement of mental status to be very
poor. By the end of his stay, it was the opinion of both the
primary team and the neurology service that the patient was in a
persistent vegetative state.
2) Hypoxic respiratory failure
The patient was maintained on assist-control for the majority of
the hospital stay, demonstrating very good oxygen saturations.
On [**7-6**] patient was transitioned to pressure support ventilation
which was well tolerated. ABG notable for respiratory acidoses
but good oxygenation. On day before discharge patient weaned to
tracheostomy mask, again ABG showed good oxygenation with mild
respiratory acidosis with appropriate compensation.
3) End stage renal disease: The pt presented with acute on
chronic renal failure with Cr 3.3 from baseline of 2.4. During
his course, he developed progressive oliguria despite diuretic
therapy. The etiology of the pt's worsening renal function was
most likely pre-renal failure and ATN in setting of
intravascular volume loss [**12-27**] GI bleed.
Despite aggressive medical diuresis and hydration, the pt
continued to have worsening renal function by elevated
creatinines and volume overload. The pt also became increasingly
obtunded felt to be secondary to uremia. The pt was , therefore
started on HD and an HD tunnel catheter was placed on [**2187-6-26**].
Pt received hemodialysis on a Monday, Wednesday, Friday
schedule. His creatinine stabilized. He did appear to have
uremic platelet dysfunction on [**7-6**] which resolved (see
4) Anemia: Pt had anemia likely secondary to a number of causes
including possible GI bleed on admission, bleeding secondary to
thrombocytopenia/uremic platelet syndrome, anemia of End stage
renal disease, anemia of chronic disease.
The pt's admitting HCT was 29.6 (baseline HCT 26-31). He
required 2 Units PRBC during his admission on [**6-15**]. Following
that, his hct remained stable (28-30). An EGD on admission
revealed gastritis/gasrtic erosions and no significant active
bleeding. Colonoscopy likewise revealed no active bleeding,
though did reveal transverse and sigmoid colon polyps and
internal hemorrhoids. Iron studies, vit B12, folate were normal.
Retic count was normal as were LDH and haptoglobin. Given this
data, the pt's anemia did not appear to be secondary to
deficiency, destruction, or under-production.
The pt's anemia was felt to be likely secondary to a slow GI
bleed, possibly from gastric erosions. Stool specimens were
C.diff negative, Cx negative, campylobacter neg, and negative
for O and P. Therefore unlikely infectious etiology of GI bleed.
During his admission he received IV Protonix 40 mg [**Hospital1 **], this was
eventually changed to lansoprazole given though PEG.
On [**2187-6-27**] patient noted to have generalized bleeding in several
area including tracheostomy site, IV line insertion areas. He
was noted to have a decrease hematocrit and was transfused four
units of pRBC over the next two days, also received. Also
noted to have purpuric lesions and decreased platelets. HIT
sent, returned as negative. Rec'd 1 unit platelets. Platelets
normalized over next few days. His hematocrit stabilized and
pt required no further transfusions. The bleeding was felt to
be secondary to uremic platelet syndrome. Hematocrit was
generally stable as was the platelet count for rest of hospital
course.
Patient received epoetin treatment on hemodialysis days.
.
5) VAP: Pt had two occurrences of ventilator associated
pneumonia.
Upon admission, the pt had been on ceftaz/vanco since [**6-4**] given
increased secretions, infiltrates on CXR, though no documented
fever. A sputum on [**6-11**] grew out ceftaz sensitive Pseudomonas.
His vanc was d/c'd as he had been given a seven day course and
had no identifiable Gram positive organism grown out of cx. His
ceftazidime was continued on a 21 day course. Flagyl was added
on [**6-18**] for coverage of potential anaerobes, given a question of
aspiration.
The pt was followed clinically and radiographically throuigh
serial CXRs. As of [**6-21**] CXRs demonstrated resolution of the pt's
upper lobes opacities, though with worsening of the lower
lobes. Pt was afebrile however.
On [**2187-7-9**] pt noted to be in respiratory distress with fever,
increased respiratory rate and increased secretions. White
blood cell count elevated. Pt started on levofloxacin and
flagyl. Also on ampicillin given elevated LFTs that day for
possible acalculous cholecystitis (see below). Sputum culture
grew gram negative rods, chest x-ray show mildly increased
infiltrates but no effusion or consolidation.
Pt improved over next few days, defervescing with resolution of
respiratory distress. WBC returned to [**Location 213**]. Some resolution
of infiltrates on CXR. Less secretions noted. By discharge,
pneumonia had resolved. Pt discharged on antibiotic course of
levofloxacin and flagyl to complete on [**2187-7-23**].
Pt received alb/atr nebs and home fluticasone throughout
admission.
5) Transaminitis/biliary sludge. Pt noted to have markedly
elevated LFTs with some biliary sludge noted on RUQ ultrasound.
No gallstones seen. On [**7-9**] pt had fever and again had LFTs
elevated; this was concerning for acalculous cholangitis and pt
started on ampicillin. Repeat RUQ u/s showed no evidence of
this. Ampicillin was discontinued. Other than being briefly
intolerant to tube feeds, pt showed no signs on abdominal exam
consistent with biliary disease although his LFTs were generally
elevated throughout admission.
6) CAD: s/p CABG X 4 [**2-27**].
- hold ASA given suspected GI bleed
- unclear why patient is noTnT leak likely [**12-27**] decreased
clearance in the setting of acute on chronic renal failure. Will
monitor to ensure downward trend.
.
7) HTN: Proved difficult to control in setting of meds if
remains hemodynamically stable now adequate on labetalol,
amlodipine, hydralazine, and his dialysis.
.
11) Access: PIV, L PICC line (placed [**7-10**]), and tunneled cath
.
12) Code: Full code
.
13) Communication: HCP daughter [**Name (NI) 21105**] [**Name (NI) 21106**] (H:
[**Telephone/Fax (1) 21107**], C: [**Telephone/Fax (1) 21108**])
Medications on Admission:
1) Prevacid 30 mg PGT [**Hospital1 **]
2) Haldol 0.5 mg PGT [**Hospital1 **]
3) Ceftazidime 1 g IV q8h (started [**6-4**])
- vancomycin stopped [**6-9**] for elevated trough
4) Amlodipine 10 mg PGT daily
5) Ascorbic acid 500 mg PGT [**Hospital1 **]
6) Casec powder 2 tbsp PGT [**Hospital1 **]
7) Colace 100 mg PGT [**Hospital1 **]
8) Ferrous sulfate 300 mg PGT [**Hospital1 **]
9) Heparin 5000 u SC q12h
10) Hydralazine 50 mg PGT q6h
11) Ipratroprium INH QID and q4h prn
12) Labetolol 400 mg PGT q8h
13) Xopenex 0.63 mg neb TID and q4h prn
14) MV1 PGT daily
15) Senna 10 ml PGT [**Hospital1 **]
16) Dulcolax prn
17) Lactulose prn
18) Tylenol prn
19) NPH 20 u SC BID RISS
20) ECASA 325 mg PO daily
21) Fluticasone MDI 220 mcg INH q12h
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-26**]
Puffs Inhalation Q4H (every 4 hours).
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-26**]
Drops Ophthalmic PRN (as needed).
5. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) suspension PO DAILY (Daily).
6. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
7. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic PRN (as needed).
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed for constipation.
9. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) mL PO BID
(2 times a day) as needed.
10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
14. Phenytoin 100 mg/4 mL Suspension Sig: 6.4 mL PO TID (3 times
a day): Please give phenytoin 3 hours after tube feed.
15. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Packet Sig: Two
(2) Packet PO BID (2 times a day).
16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
17. Levofloxacin in D5W 250 mg/50 mL Piggyback Sig: Fifty (50)
mL Intravenous Q24H (every 24 hours): End date [**2187-7-23**].
18. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One Hundred (100) mL Intravenous Q8H (every 8 hours): End date
[**2187-7-23**].
19. Morphine 2 mg/mL Syringe Sig: 0.25 mL Injection Q4H (every 4
hours) as needed.
20. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
21. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Five (5)
units Subcutaneous twice a day: at 8 am and 8 pm. If dose to be
increased, please increase with caution.
22. Humalog 100 unit/mL Cartridge Sig: Three (3) units
Subcutaneous four times a day: Please give 3 units humalog 15
minutes before tube feedings. If need to increase dose, please
increase cautiously.
23. Tube feedings.
Please give tube feedings for times a day 6 am, 12 noon, 6 pm,
midnight. Full strength Nepro with promod. See page 1
referral.
24. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
25. Insulin
Goal blood sugar is 140-180. Titrate up humalog and NPH
ONE unit at a time to acheive this goal.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 4480**] [**Hospital 4094**] Hospital - [**Location (un) 1110**]
Discharge Diagnosis:
Hypoxic respiratory failure.
Prolonged weaning from ventilatory requiring placement of
tracheostomy and PEG.
Persistent vegetative state.
Seizure disorder s/p stroke.
Hypoglycemic episode on [**2187-6-28**] with associated seizure
activity.
Ventilator Associated Pneumonia secondary to MRSA, Pseudomonas.
Ventilator Associated Pneumonia secondary to gram negative rods,
unspeciated.
Transaminitis.
Thrombocytopenia, now resolved.
Anemia of chronic disease.
Anemia secondary to suspected lower GI bleed.
End stage renal disease requiring hemodialyisis.
Anemia secondary to renal disease.
Renal hypertension.
Uremia with resulting encephalopathy and platelet dysfunction.
Coronary Artery Disease s/p cor a bypass graft surgery.
Discharge Condition:
Obtunded, suspected persistent vegetative state.
Medically, condition is fair. Breathing through tracheostomy
without ventilatory support, afebrile, hemodynamically stable
but hypertensive. Hematocrit stable. Tolerating hemodialysis,
no current signs of uremia.
Discharge Instructions:
Please continue hemodialysis on Monday, Wednesday, Friday
schedule.
Please continue dilantin therapy.
Please continue antibiotic therapy for total of two weeks, end
date [**2187-7-23**].
Please continue to use CONSERVATIVE blood glucose management
given episode of hypoglycemia. Goal blood glucose eventually
100-150, cautiously increase dose of humalog and/or NPH.
Followup Instructions:
Extended care in rehabilitation facility.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"5845",
"40391",
"4280",
"V4581",
"V5867"
] |
Admission Date: [**2126-4-20**] Discharge Date: [**2126-4-22**]
Date of Birth: [**2080-7-25**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Right hand clumsiness, slurred speech, word finding difficulty
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: 45 year old right handed man with h/o borderline HTN, OSA,
who
complains of acute onset of speech problems.
[**Name (NI) **] has had cough and muscle aches for the last three
days. He did not take his temperature. He had no neurological
deficits during the evening of [**4-19**]. He awoke this morning and
was
typing on his computer at 6:30am when he noted that his right
hand was clumsy. Patient went to the grocery store. At 7:30am he
had acute onset of slurred speech. He returned home and awoke
his
wife at 7:45am. She thought that he had slurred speech and
word-finding difficulty. He was speaking slowly with decreased
fluency. He also had tingling of his left hand.
Patient denies difficulty understanding her. She did not
observe a facial droop. Patient denied headache, vertigo, visual
field abnormalities, or gait instability.
He called his PMD who urged him to visit the office. In the
office at 8:30am, the PMD told him to go to the ED.
Stroke code was called at 8:55am. Stroke fellow was at
bedside at 8:58am. His vitals were SBP 180, pulse 92, and fs
102.
His NIHSS was 2 (-1 for mild to moderate dysarthria, -1 for
decreased word finding and decreased fluency).
CT brain showed no acute infarct or bleed. CTA brain showed
no cutoff of any intracranial vessel. Patient was not a
candidate
for TPA due to minimal deficits and lack of vessel cutoff on CTA
brain.
His blood pressure was difficult to control despite
Labetalol
10mg iv x3, and Hydralazine 10mg iv. His BP was 213/148 at
10:05am. Nicardipine gtt was started. He was admitted to the
ICU.
Past Medical History:
Borderline HTN
Obstructive sleep apnea
Social History:
General manager for [**Company 86**] Wine Co, lives with his wife and 4
children (17, 15, 13, 10), no tobacco, + social EtOH
Family History:
Father had a stroke at 57 and several MIs in his 70s, died
during CABG, mother has had [**8-20**] MIs, femoral a. bypass, carotid
disease, hypertension, hyperlipidemia
Physical Exam:
T- 96.1 BP- 184/130 HR- 91 RR- 21 O2Sat- 97% on RA
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
Back: No point tenderness or erythema
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema
NIHSS = 1 (dysarthria)
PE
VS: Tc 99.1 BP 213/148 P 90's R 16 02 98% on RA
Gen: WD/WN
Heent: supple neck, no carotid bruits, no lymphadenopathy
Chest: lungs clear to auscultation bilaterally, no wheezes,
rales, or rhonchi
Heart: regular rate and rhythm, no murmurs,
Abd: soft, non-distended, non-tender, no mass, positive bowel
sounds
Ext: no cyanosis, clubbing, or edema
Skin: no erythema
Neuro: MS: alert and oriented x3, mildly decreased fluency, In
describing the Cookie Theft picture, he incorrectly stated that
the child was dropping a plate. He accurately describing the
woman washing the dish with the sink overflowing. He
occasionally
had difficulty finding the right word. intact comprehension,
intact naming, repetition, knowledge, calculation, spelling,
immediate recall [**4-15**], short term recall [**4-15**], follows crossed
body
commands, no neglect or apraxia
CN: mild to moderate dysarthria, visual fields full to
confrontation, no papilledema, pupils equal, round, and
reactive,
extraocular movements intact, intact light touch, intact facial
strength and symmetry, intact t/u/p, [**6-17**] SCM and trapezius
Motor: mildly impaired fine finger movements of the right hand
normal tone and bulk of all four extremities, no tremor
D B T WE WF FE FF
Left 5 5 5 5 5 5 5
Right 5 5 5 5 5 5 5
IP Q H DF PF
Left 5 5 5 5 5
Right 5 5 5 5 5
Sensory: intact light touch and pinprick of all four extremities
intact vibration and proprioception of UE
intact proprioception of LE
no extinction
Reflex: T BR B K A toes
Left 2 2 2 2 2 down
Right 2 2 2 2 2 down
Coord: Intact finger-nose-finger, heel-shin, and rapid
alternating movements bilaterally
Gait: deferred
Pertinent Results:
Na:140 K:4.1 Cl:103 TCO2:22 Glu:93
Trop-T: <0.01
WBC 4.3 Hgb 16.2 Plt 311 Hct 45.9 MCV 86
PT: 11.9 PTT: 27.6 INR: 1.0
<br>
IMAGING:
CT brain non-contrast: No acute infarct or bleed.
CTA brain: No intracranial vessel filling defect
<br>
CXR: No acute cardiopulmonary abnormality
<br>
MR brain: [**4-20**]: Acute left-sided subcortical lacunar infarct in
the basal ganglia periventricular region. Mild changes of
small-vessel disease.
MRA head: normal MRA
<br>
ECHO: The left atrium is normal in size. No atrial septal defect
or patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%) The estimated cardiac index is normal (>=2.5L/min/m2).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. There is no
aortic valve stenosis. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Normal study. No definite structural cardiac source
of embolism identified.
If clinically indicated, a TEE with saline contrast/maneuvers
would be more sensitive for a suspected patent foramen ovale.
CLINICAL IMPLICATIONS:
Based on [**2125**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
Mr. [**Known lastname 35041**] was initially admitted to ICU for BP management with
elevated SBPs >200s. He was started on nicardipine gtt with
improvement in BPs. He was started on PO metoprolol with
dropping of his pressures to SBP 120s. He received IVF with
improved SBPs in 140-160s. Nicardipine was weaned off
simultaneously. He had a stable neurologic exam with stable BPs
while in the ICU.
MRI did confirm a lacunar infarct in the left basal ganglia and
periventricular subcortical region. He was treated with
acetaminophen prn for euthermia and insulin sliding scale for
euglycemia. He was started as above on metoprolol for long-term
blood pressure control, atorvastatin for long-term cholesterol
control (goal LDL < 70), and daily full-dose aspirin as an
anti-platelet [**Doctor Last Name 360**] for secondary prevention.
Echo was unremarkable. A1c was 5.4; total cholesterol was 187,
LDL was 119.
He was discharged with a prescription for speech therapy for his
dysarthria. He will follow-up with Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] in Stroke
Neurology. He was instructed to follow-up with his PCP [**Name Initial (PRE) 176**] 2
weeks for BP monitoring.
Medications on Admission:
Azithromycin (started yesterday for URI)
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*2*
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 2 doses.
5. Outpatient Speech/Swallowing Therapy
Please provide evaluation and treatment for dysarthria.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Cerebral infarct (Stroke) of the left basal ganglia and
subcortical white matter.
Secondary:
1. Hypertension
2. Hypercholesterolemia
Discharge Condition:
Good condition, neuro exam notable for mild dysarthria and right
hand clumsiness.
Discharge Instructions:
You have been evaluated for slurred speech and right hand
clumsiness and were found to have had a stroke. You were started
on aspirin, metoprolol for your blood pressure, and a statin
drug for your cholesterol. Please take all medications as
directed and keep all follow-up appointments.
It is usual for a stroke of this sort to have symptoms that come
and go for the first 1-2 weeks, after which it will stabilize
and gradually improve over the next several months. However, if
you have worsening of your symptoms after this 2 week window, or
if you have new symptoms such as difficulty speaking, difficulty
swallowing, dizziness, double vision, weakness, numbness, or any
other symptom that is concerning to you, please call your PCP or
your neurologist or go to the nearest hospital emergency
department.
Followup Instructions:
You have the following appointment scheduled in [**Hospital **]
clinic:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2126-6-21**] 9:30
<br>
Please also call your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**], at [**Telephone/Fax (1) 2205**]
as soon as possible to schedule a follow-up appointment to be
seen in [**2-13**] weeks.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2126-4-22**]
|
[
"4019",
"2720",
"32723"
] |
Admission Date: [**2166-1-13**] Discharge Date: [**2166-2-12**]
Date of Birth: [**2101-7-30**] Sex: M
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Evaluation for liver transplant
Major Surgical or Invasive Procedure:
Multiple paracenteses
CVVH
Multiple bone marrow biopsies
Multiple blood transfusions
Central line placement
History of Present Illness:
64 yo M with h/o alcoholic and ?HCV cirrhosis transferred from
[**State 792**]Hospital for decompensated liver failure. Pt was
admitted to OSH [**2165-12-26**] for an elective TIPS procedure for
refractory ascites. Pt underwent TIPS on [**2165-12-26**] complicated
by liver laceration and massive hemorrhage requiring
transfusion. He subsequently underwent IR embolization of
superior medial liver segment via the right superior
subsegmental branch (segment 8). Following embolization on [**12-27**]
the pt was transferred to the SICU, and on [**2165-12-28**] pt
underwent TIPS revision by IR using a covered endograft stent
extending the TIPS shunt slightly further into the main portal
vein, excluding part of the left portal vein and right portal
vein branches in an attempt to stop bleeding felt to be
originating at either the extracapsular portion of the shunt or
possibly a right posterior and inferior portal vein branch. Pt's
mental status continued to be poor following TIPS revision, and
lactulose was started for hepatic encephalopathy. He was finally
intubated on [**2166-1-3**] for worsening mental status and hypoxia.
Pt was treated for sepsis with broad spectrum abx and ?PNA, now
only being treated with zosyn. During the last week patient was
been more stable, weaning on his pressors (currently on
vasopress in only) and is being transferred for urgent
transplant evaluation. According to [**Location (un) **] pt had an episode
of seizure activity on transfer, for which he received 2mg of
ativan and this resolved.
Past Medical History:
Past Medical History: EtOH/HCV cirrhosis
.
Past Surgical History:
[**2165-12-26**] TIPS procedure
[**2165-12-27**] IR embolization of subsegmental branch of RHA (segm 8)
[**2165-12-28**] TIPS revision and 4L paracentesis
Social History:
Social History: h/o EtOH abuse (last drink 4 months ago)
Family History:
Family History: Unknown at this point.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
T 95.6 HR 67 BP 99/71 RR 18 SO2 100%/CMV 50% 460x18 PEEP 10
General: Intubated, off sedation. Skin macerated. Ecchymotic
lesions throughout the extremities and flanks.
Neuro: Non-responsive off-sedation. No voluntary movements, does
not respond to pain. Appropriate pupillary, corneal and ME
reflexes.
Lungs: Diminished breath sounds on both bases.
Cardiac: Regular rate and rhythm, S1/S2
Abd: Soft, mod to severe distension (ascites), nontender.
Rectal: Normal tone, no gross blood, guaiac negative
Extrem: Warm, well-perfused, 2+ edema bilaterally.
Pertinent Results:
Admission labs:
[**2166-1-13**] 11:58PM BLOOD WBC-0.7* RBC-3.18* Hgb-9.9* Hct-28.2*
MCV-89 MCH-31.1 MCHC-35.0 RDW-20.6* Plt Ct-33*
[**2166-1-13**] 11:58PM BLOOD Neuts-24* Bands-0 Lymphs-42 Monos-28*
Eos-2 Baso-0 Atyps-4* Metas-0 Myelos-0
[**2166-1-13**] 11:58PM BLOOD PT-33.6* PTT-44.3* INR(PT)-3.4*
[**2166-1-13**] 11:58PM BLOOD Fibrino-114*
[**2166-1-13**] 11:58PM BLOOD Glucose-201* UreaN-137* Creat-6.9* Na-139
K-4.5 Cl-103 HCO3-14* AnGap-27*
[**2166-1-13**] 11:58PM BLOOD ALT-18 AST-22 LD(LDH)-275* AlkPhos-59
Amylase-102* TotBili-6.2*
[**2166-1-13**] 11:58PM BLOOD Lipase-138*
[**2166-1-13**] 11:58PM BLOOD Albumin-3.1* Calcium-8.3* Phos-9.2*
Mg-3.1* Iron-91
[**2166-1-13**] 11:58PM BLOOD calTIBC-91* Hapto-44 Ferritn-[**2104**]*
TRF-70*
Please see attached paperwork with lab trends.
[**2166-1-14**] Blood (Toxo) TOXOPLASMA IgG ANTIBODY-FINAL;
TOXOPLASMA IgM ANTIBODY-
**FINAL REPORT [**2166-1-14**]**
TOXOPLASMA IgG ANTIBODY (Final [**2166-1-14**]):
NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
0.0 IU/ML.
Reference Range: Negative < 4 IU/ml, Positive >= 8 IU/ml.
TOXOPLASMA IgM ANTIBODY (Final [**2166-1-14**]):
NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
[**2166-1-14**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB-FINAL;
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-FINAL; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM
AB-FINAL
**FINAL REPORT [**2166-1-16**]**
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB (Final [**2166-1-16**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB (Final [**2166-1-16**]): POSITIVE
BY EIA.
[**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB (Final [**2166-1-16**]):
NEGATIVE <1:10 BY IFA.
[**2166-1-14**] 11:58 am IMMUNOLOGY **FINAL REPORT [**2166-1-15**]**
HCV VIRAL LOAD (Final [**2166-1-15**]):
HCV-RNA NOT DETECTED.
[**2166-1-14**] Blood (CMV AB) CMV IgG ANTIBODY-FINAL; CMV IgM
ANTIBODY-
CMV IgG ANTIBODY (Final [**2166-1-14**]):
POSITIVE FOR CMV IgG ANTIBODY BY EIA. 8 AU/ML.
Reference Range: Negative < 4 AU/ml, Positive >= 6 AU/ml.
CMV IgM ANTIBODY (Final [**2166-1-14**]):
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: INFECTION AT UNDETERMINED TIME.
[**2166-1-14**] SEROLOGY/BLOOD VARICELLA-ZOSTER IgG SEROLOGY-
VARICELLA-ZOSTER IgG SEROLOGY (Final [**2166-1-14**]):
POSITIVE BY EIA.
[**2166-1-14**] SEROLOGY/BLOOD Rubella IgG/IgM Antibody-
Rubella IgG/IgM Antibody (Final [**2166-1-14**]):
POSITIVE by Latex Agglutination.
[**2166-1-14**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST
**FINAL REPORT [**2166-1-14**]**
RAPID PLASMA REAGIN TEST (Final [**2166-1-14**]):
NONREACTIVE.
Reference Range: Non-Reactive.
Micro:
[**2166-2-10**] RESPIRATORY CULTURE- YEAST
[**2166-2-10**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-negative
[**2166-2-9**] Ascitic Fluid Culture - NGTD
[**2166-2-3**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-negative
[**2166-2-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-negative
[**2166-2-1**] PLEURAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-no
growth; ANAEROBIC CULTURE-no growth
[**2166-2-1**] CATHETER TIP-IV WOUND CULTURE-no growth
[**2166-2-1**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-F{YEAST}
[**2166-2-1**] URINE URINE CULTURE-FINAL
[**2166-1-31**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE- no
growth; ANAEROBIC CULTURE-no growth
[**2166-1-31**] BLOOD CULTURE - no growth
[**2166-1-31**] BLOOD CULTURE - no growth
[**2166-1-31**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
{YEAST}
[**2166-1-23**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE- no
growth; ANAEROBIC CULTURE- no growth; FUNGAL CULTURE-no growth;
ACID FAST SMEAR-- no growth; ACID FAST CULTURE-NGTD
[**2166-1-19**] Ascitic fluid cx-no growth
[**2166-1-19**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-no
growth; ANAEROBIC CULTURE-no growth; ACID FAST CULTURE-NGTD;
ACID FAST SMEAR-FINAL
[**2166-1-15**] Mini-BAL GRAM STAIN-FINAL; RESPIRATORY CULTURE-no
growth; POTASSIUM HYDROXIDE PREPARATION-FINAL; FUNGAL
CULTURE-{YEAST}
[**2166-1-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-negative
[**2166-1-14**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-no
growth; ANAEROBIC CULTURE--no growth; FUNGAL CULTURE-no growth
[**2166-1-14**] BLOOD CULTURE -no growth
[**2166-1-14**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-no
growth
[**2166-1-14**] URINE CULTURE - no growth
[**2166-1-13**] BLOOD CULTURE - no growth
[**2166-1-13**] BLOOD CULTURE - no growth
Imaging:
CXR [**2-10**]:
Some air is now present within the left lung, though a large
left hemothorax is still present with mediastinal shift.
IMPRESSION: Some re-expansion of left lung. Mediastinal shift
persists.
CT torso [**2-7**]:
CT OF THE CHEST: There is a large left pleural effusion,
distributed in
almost entire left hemithorax, leading to right-sided
displacement of
mediastinal structures. The remnant left lung tissue seen
predominantly in
the anterior aspect of the left hemithorax demonstrates diffuse
ground-glass opacities. The left pleural effusion demonstrates
layering of the fluid with dependent area measures 40 Hounsfield
units in attenuation, consistent with hemorrhagic component.
There is moderate right pleural effusion measuring 15 [**Doctor Last Name **] in
attenuation with adjacent areas of compressive atelectasis,
essentially
unchanged from [**2166-1-30**] exam. The visualized portions of
the right
lung demonstrates diffuse opacities which are likely infectious
in etiology. The heart is of normal size without pericardial
effusion. The right and left internal jugular central venous
catheters terminate within the SVC. The endotracheal tube
terminates several centimeters above the carina.
CT OF THE ABDOMEN: There is massive ascites within the abdomen,
unchanged
from [**2166-1-30**] exam. There is hyperdense fluid material in
the most
dependent area within the left upper abdomen measuring 70
Hounsfield units in attenuation suggestive of the hemorrhagic
component. The liver is markedly diminished in size. The surface
morphology appears nodular, consistent with cirrhosis. A TIPS
shunt is in unchanged position. Within limitations of a
non-contrast exam, spleen, adrenal glands, and kidneys appear
unremarkable.
An IVC filter within the infrarenal IVC is noted.
Intra-abdominal aorta is
notable for calcified atherosclerotic disease without aneurysmal
changes.
CT OF THE PELVIS:
A Foley catheter is in place. Large amount of fluid within the
pelvis is
noted. There is no free air. The rectum is displaced posteriorly
and there
is an adjacent area of hyperdense fluid measuring 50 Hounsfield
units in
attenuation, consistent with hemorrhagic fluid.
OSSEOUS STRUCTURES:
No suspicious lytic or sclerotic lesions are seen.
IMPRESSION:
1. Large left pleural effusion with hemorrhagic component with
right-sided
displacement of the mediastinal structures.
2. Moderate right pleural effusion, unchanged from [**2166-1-30**] exam.
3. Visualized portions of the lungs demonstrate diffuse
opacities, likely
infectious in nature.
4. Massive amount of ascites, unchanged from [**2166-1-30**]
exam, however, there are areas of hyperdense fluid within the
left upper abdomen and pelvis with high attenuation, consistent
with hemorrhage.
5. The liver is markedly diminished in size and nodular in
morphology
consistent with cirrhosis. A TIPS shunt is in unchanged
position.
CTA abd/pelvis [**1-30**]:
IMPRESSION:
1. Cirrhosis, splenomegaly, and varices. Changes of
chemoembolization and
TIPS. Resolving hemoperitoneum, without evidence of active
extravasation.
2. Enlarging left and stable moderate right pleural effusions.
3. Bibasilar consolidation, consistent with pneumonia.
4. L2 compression fracture and L1-L3 posterior fixation.
5. Post-pyloric tube placement.
Bone marrow biopsy [**1-27**]:
DIAGNOSIS:
CELLULAR BONE MARROW WITH TRILINEAGE MATURING HEMATOPOIESIS,
INCREASED HISTIOCYTES AND MORPHOLOGIC FEATURES HIGHLY SUGGESTIVE
OF MARROW INJURY. SEE NOTE.
Note: The bone marrow evaluation is significant for evidence of
cellular injury and macrophage infiltration with frequent
hemophagocytic histiocytes in a background of left-shifted
myelopoiesis and reactive plasmacytosis. The findings are
similar to the patient's previous bone marrow biopsy, and the
differential diagnostic considerations for marrow injury include
drugs/medication, toxins, infections, metabolic and immune
causes. The presence of hemophagocytic histiocytes is itself a
non-specific finding and must be interpreted in the appropriate
clinical context. Importantly, neutropenia developed after the
TIPS procedure and in concert with metabolic decompensation.
MICROSCOPIC DESCRIPTION
Peripheral Blood Smear:
Erythrocytes are decreased and exhibit marked anisocytosis with
microcytic and macrocytic forms, and marked poikilocytosis with
numerous echinocytes, acanthocytes, and scattered red cell
fragments and schistocytes. Few forms with coarse basophilic
stippling and Pappenheimer bodies are seen. The white blood
cell count appears markedly decreased. Neutrophils include some
forms with toxic granulation. Rare hemophagocytic histiocytes
are noted. platelet count appears markedly decreased.
differential shows: 5% neutrophils, 0% bands, 26% lymphocytes,
43% monocytes, 25% eosinophils, 1% basophils.
Aspirate Smear:
The aspirate material is adequate for evaluation. It consists of
several cellular spicules. any background histiocytes are
present, some containing ingested debris and several with
ingested marrow precursor cells and erythrocytes
(hemophagocytosis). The M:E ratio is 1.6:1. Erythroid
precursors are normal n number with normoblastic maturation.
myeloid precursors appear normal in number and show left-shifted
maturation. Megakaryocytes are present in decreased numbers.
Based on a 500 cell Differential: 2% Blasts, 31% Promyelocytes,
14% Myelocytes, 2% Metamyelocytes, 3% Bands/Neutrophils, 11%
plasma cells, 2% Lymphocytes, 35% Erythroid.
Clot Section and Biopsy Slides:
The biopsy material is adequate for evaluation, and consists of
trabecular bone with an overall marrow cellularity of 40-50%.
Scattered collections of histiocytes containing ingested debris
and cellular material are present. Plasma cells are abundant
and present singly and in small clusters, comprising
approximately 20% of overall cellularity. Focal marrow fibrosis
is seen. The M:E ratio estimate is normal. Erythroid precursors
are normal in number and have normoblastic maturation. Myeloid
elements are normal in number and exhibit normal maturation.
Megakaryocytes are present in decreased numbers. Marrow clot
section adds no additional information. The findings are very
similar to those seen on a previous bone marrow biopsy
(S10-[**Numeric Identifier **], M10-735).
CT head [**1-14**]:
IMPRESSION: No evidence for an acute intracranial process.
Abd US [**1-14**]:
IMPRESSION:
Nodular cirrhotic liver, TIPS stent in situ, which is patent
with normal flow. The main portal vein is patent with normal
flow. The hepatic veins and hepatic artery patent with normal
flow. Large amount of intra-abdominal ascites.
TTE [**1-14**]:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 60%). The right ventricular cavity is markedly
dilated with depressed free wall contractility. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. Tricuspid
regurgitation is present but cannot be quantified. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
CT torso [**1-14**]:
IMPRESSION:
1. Large amount of intra-abdominal and intrapelvic free fluid
with Hounsfield units suggesting a combination of ascites and
hemoperitoneum consistent with patient's known ascites and
recent liver laceration.
2. Bilateral patchy airspace consolidations are suggestive of
multifocal
pneumonia. There is also bilateral moderate pleural effusions
with adjacent relaxation atelectasis.
3. Shrunken liver consistent with cirrhosis with hyperdense
material in
segment VII and VIII consistent with recent embolization. TIPS
catheter is
visualized in place from the main portal vein to the inferior
vena cava.
4. L2 compression fracture with L1 through L3 posterior fixation
and
bilateral pedicular screws through L1 and L3.
5. Gastric tube and endotracheal tube tips remain in place.
Brief Hospital Course:
SICU course [**2166-1-13**] - [**2166-2-4**]
Mr. [**Known lastname **] was admitted to the SICU with fulminant liver failure
following a TIPS procedure complicated by a bleed requiring
embolization of segment 8 and revision of his TIPS. On initial
admission, his GCS was 3. He was transferred from [**State 40074**]Hospital intubated and on levophed for blood pressure support.
A full workup for transplant listing was initiated which
included serologies, liver duplex, ECHO, CT Torso, CT head and
placement of a Dobhoff tube postpyloric for feeding. An initial
CT scan of his head was negative for any significant pathology
and it was felt that his current mental status was likely due to
his liver failure. Neurology was consulted for evaluation of
his mental status and during that time he had a tonic-clonic
seizure for which he was loaded and maintained on Keppra. An
initial diagnostic paracentesis of his abdomen excluded
spontaneous bacterial peritonitis and CVVH was initiated for his
acute renal failure after his acute decompensation at [**Hospital 13548**]Hospital. He was intially treated with zosyn at [**Hospital 13548**]Hospital during his decompensation and shortly after the
start of zosyn, he developed neutropenia. His zosyn was
discontinued here, and cefepime was started emprically for his
pneumonia. A BAL culture eventually grew yeast and he was
started on fluconazole for coverage.
Hematology was consulted regarding his neutropenia and a bone
marrow biopsy was performed on [**2166-1-16**] which eventually showed
agranulocytosis, likely acute reaction to acute illness or
medication. He continued to remain neutropenic and
coagulopathic from his liver disease with intermittent need for
trasnfusions. He also remained on CVVH for fluid removal, with
an inability to tolerate HD due to labile blood pressures. His
mental status improved and on [**1-17**], he was arousable and able
to follow commands.
On [**2166-1-21**] he continued to require ventilatory support, but was
awake and following commands. He underwent a therapeutic
paracentesis for 7 liters of ascitic fluid. The cefepime was
discontinued with no positive culture data and levofloxacin was
started for neutropenic prophylaxis. He underwent a second
paracentesis on [**2166-1-24**] for 2.2 liters. He continued to remain
neutropenic with a WBC of 0.7 with the continuation of his
neupogen and he continued to require intermittent CVVH for fluid
removal. Attempts to wean him from ventilatory support failed
and he continued to remain coagulopathic from his liver disease.
A repeat bone marrow biopsy was performed on [**2166-1-27**] and during
this time had a hypotensive episode requiring neosynephrine for
blood pressure support. He was eventually weaned from his
requirement for neosynephrine. The bone marrow biopsy did not
demonstrate any signs of a malignant process and on [**2166-1-28**] his
WBC started to increase (1.4). He remained intubated with an
inability to be weaned, likely secondary to his deconditioned
state. His neutropenia continued to improve with a WBC of 2.7
on [**1-30**] and 5.5 on [**1-31**]. Although he had a normal WBC on [**2166-1-31**],
he remained neutropenic and developed a neutropenic fever to
101.6 that morning with hypotension requiring neosynephrine and
empiric vancomycin, meropenem, and micafungin was started and
later stopped without positive culture data. Multiple cultures
were sent with only positive cultures growing yeast, the last of
which was [**2166-2-1**] from a BAL. He continued to remain
coagulopathic with a need for intermittent blood product
transfusions and on ventilatory support for his deconditioned
respiratory failure. He also remained on neosynephrine without
a clear etiology.
On [**2166-2-4**], it was decided at liver allocation meeting that Mr.
[**Known lastname **] was not a liver transplant candidate. Dr. [**Last Name (STitle) 497**] had an
extensive meeting with the family to notify them that he would
not be listed for liver transplant and his care was transitioned
to the MICU service at this time.
=====================
MICU Course [**Date range (3) 87707**]
# Hypotension: The patient was transferred with continued need
for pressors (neo). Initially was felt hypovolemia as patient
was 3L net negative for LOS. However, hct began to trend down
with an 8 point hct drop over 12 hours on [**2166-2-6**]. CXR and CT
chest revealed hemothorax on left where left HD line had been
placed. Given his tenuous clinical status and his lack of
synthetic function making clotting difficult it was decided not
to evacuate this with a chest tube but instead to support him
with blood products, including platelets and cryo. His hcts did
stabilize, however, he still required pressor support.
Anitbiotics were broadened to Vanc(day [**2166-2-7**] for a planned 7
day course)/aztreonam(day [**2166-2-7**] for a planned 7 day
course)/cipro(day [**2166-2-7**] for a planned 7 day course)/flagyl(day
[**2166-2-7**] for a planned 7 day course)/micafungin(day 1 [**2166-2-1**] for
a planned 14 day course for yeast in the sputum) in the hope of
treating a septic etiology but he continued to be reliant on neo
to keep MAPS>60. At this point it was felt the hypotension may
be secondary to vasodilation in setting of liver failure.
Midodrine was added on [**2-11**] and uptitrated to 5 mg po tid on
[**2-12**] in hopes of weaning him off neo.
# Respiratory Failure: Patient was transferred to the MICU after
having been intubated for >40days. Tracheostomy had been
deferred in SICU [**2-26**] neutropenia, however, on transfer to MICU
patient was no longer neutropenic. Unfortunately, patient did
develop the hemothorax (see above) and continued to require
pressor support so tracheostomy was deferred. Additionally
concerns regarding a trach in the setting of his coagulopathy
prevented pursual of trach placement. He failed daily SBTs and
required assist control ventilation likely due to deconditioning
from his prolonged hospitalization.
# Acute Renal Failure: Thought [**2-26**] hepato-renal syndrome.
Patient was transferred to the MICU on CVVH. In setting of
hypotension CVVH was initially run even and then with hemothorax
around HD line discontinued. His creatinine contineud to trend
up off CVVH ([**2-12**] is 5 days off CVVH). Renal did not feel CVVH
was indicated as he was not a transplant candidate and that he
would be unable to tolerate intermittent HD in the setting of
hypotension requiring neo.
# Cirrhosis/Liver failure: Patient was initially transferred to
[**Hospital1 18**] for workup for liver transplant however was deemed not a
candidate [**2-26**] deconditioned state. Family was interested in
transfer to [**Hospital1 498**] for possible transfer and he was accepted for
transfer on [**2-12**]. During his stay in the MICU he underwent a
therapeutic paracentesis (due to abd pain from increasing
ascites) on [**2-9**] during which 6 L of ascitic fluid was removed.
Of note, he will need cipro weekly for SBP ppx once off broad
spectrum antibiotics.
# Goals of care: Multiple discussions have been held with the
patient's wife (his HCP) regarding his poor prognosis, however
she wishes for further evaluation for liver transplant. She
contact[**Name (NI) **] a transplant surgeon at [**Hospital6 15083**] who
agreed to accept him in transfer for further evaluation for
liver transplantation.
# Code status: Full code.
Medications on Admission:
Meds on transfer: Zosyn 2.25, Octreotide 1000 tid, Chlorhexidine
oral rinse, hydrocortisone 100 tid, ISS, Lactulose 40 [**Hospital1 **],
Reglan
5 tid, Protronix 40 daily, Rifaximin 400 tid, Vasopressin gtt
Discharge Medications:
1. chlorhexidine gluconate 0.12 % Mouthwash Sig: Five (5) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
3. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for irritation.
5. levetiracetam 100 mg/mL Solution Sig: Five (5) mL PO DAILY
(Daily).
6. phenylephrine HCl 10 mg/mL Solution Sig: 0.5-5 mcg/kg/min
Injection Titrate to SBP >85.
7. NPH insulin human recomb 100 unit/mL Suspension Sig: Ten (10)
units Subcutaneous twice a day.
8. insulin regular human 100 unit/mL Solution Sig: One (1)
sliding scale Injection every six (6) hours: Glucose Insulin
Dose
71-119 mg/dL 0Units
120-159mg/dL 4Units
160-199mg/dL 6Units
200-239mg/dL 8Units
240-279mg/dL10Units
280-319mg/dL12Units
320-359mg/dL14Units
360-399mg/dL16Units
> 400mg/dL Notify M.D.
.
9. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation QID (4 times a day).
10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q6H (every 6 hours) as needed for
secretions.
11. lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2
times a day).
12. midodrine 5 mg Tablet Sig: One (1) Tablet PO three times a
day.
13. lanthanum 500 mg Tablet, Chewable Sig: Two (2) Tablet,
Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
15. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
16. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Dialysis Catheter (Temporary 3-Lumen): THIN NON-DIALYSIS (VIP)
Lumen: ALL NURSES: Flush with 10 mL Normal Saline followed by
Heparin as above daily and PRN.
17. Micafungin 100 mg IV Q24H
18. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
19. Pantoprazole 40 mg IV Q12H
20. Ascorbic Acid 250 mg IV Q24H
21. Ciprofloxacin 400 mg IV Q24H
22. Aztreonam 1000 mg IV Q24H
23. MetRONIDAZOLE (FLagyl) 500 mg IV Q12H
24. Fentanyl Citrate 25-50 mcg IV Q2H:PRN pain
25. vancomycin 500 mg Recon Soln Sig: Five Hundred (500) mg
Intravenous dosed by level.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary-
Liver failure
Hypercarbic respiratory failure
Acute kidney injury likely due to hepatorenal syndrome
Hemothorax
Persistent hypotension
Secondary -
Alcoholic cirrhosis
Deconditioning
Discharge Condition:
Mental Status: Confused - always. Does not consistently follow
commands. Is not oriented to place or time.
Level of Consciousness: Alert and interactive sometimes, other
times sleepy but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were transferred to [**Hospital1 18**] from [**Hospital 792**]Hospital on
[**1-13**] for evaluation for liver transplant. You had a prolonged
hospitalization with complications including kidney failure
requiring continuous dialysis, continued respiratory failure
requiring mechanical ventilation, persistent hypotension
requiring medications to elevated your blood pressure, as well
as a bleed into your chest requiring multiple blood
transfusions. After a lengthy evaluation the liver transplant
team did not feel you were a transplant candidate.
The liver transplant team at the [**State 1558**]
agreed to accept you in transfer for further evaluation for
liver transplant.
Medication changes:
Please see the attached medication list.
Followup Instructions:
You are being transferred to the [**Hospital 1558**]
Hospital and will receive further care there.
Completed by:[**2166-2-12**]
|
[
"0389",
"486",
"51881",
"99592",
"78552",
"5845",
"2762",
"2851"
] |
Admission Date: [**2123-1-23**] Discharge Date: [**2123-2-1**]
Service: MEDICINE
Allergies:
Codeine / Morphine
Attending:[**First Name3 (LF) 19684**]
Chief Complaint:
Respiratory Distress
Major Surgical or Invasive Procedure:
none
History of Present Illness:
87 F h/o prior bulbar CVA in [**8-28**] causing dysphagia, previously
trach'ed. Presented from [**Hospital 100**] rehab where patient was noted to
be coughing. Then, in the setting of deep suctioning, pt vomited
with subsequent acute respiratory distress. Per staff, baseline
O2 sat 97% on RA.
.
In ED, found to be 89% on RA, placed on non-rebreather, but
remained tachypneic with RR in the high 40s. No ABG.
.
Pt states that she has had nausea, vomiting, and diarrhea the
past several days.
Past Medical History:
h/o Bulbar CVA's - [**8-28**]
s/p Tracheostomy [**2122-9-21**]
s/p PEG placement [**8-28**], revised [**2122-12-18**]
s/p Colectomy for recurrent colitis - [**2120-3-23**]
- s/p repair of incisional hernia in [**2121-5-23**]
s/p Appendectomy
Hypertension
Hyperlipidemia
Atrial fibrillation on Coumadin therapy
Aortic valve insufficiency
Borderline DM
Melanoma
Chronic lymphocytic leukmeia
s/p L wrist fx and ORIF in [**2112**]
s/p L cataract surgery in [**2117**]
Social History:
Currently residing at [**Hospital6 459**] for the Aged for
[**Hospital 89367**] rehabilitation. Denies tobacco use, ETOH use, or
recreational drug use
Family History:
-mother with a stroke at the age of 96
-father with a brain tumor
Physical Exam:
VS - T 97.1, BP 165/34, HR 115, RR 42, O2 sat 100% NRB
Gen - moderate respiratory distress, with accessory muscle use
and abdominal breathing, speaking short phrases with some
dysarthria
HEENT - PERRL, OP clr, MM dry
CV - irreg, irreg, tachy
Chest - coarse crackles
Abd - soft
Ext - no edema
Pertinent Results:
REPORTS:
.
CHEST (PORTABLE AP) [**2123-1-23**] 3:52 AM
AP UPRIGHT CHEST RADIOGRAPH: The cardiomediastinal silhouette is
within normal limits. The pulmonary vasculature is normal. There
is a persistent left retrocardiac opacity and small unchanged
left-sided pleural effusion.
IMPRESSION: 1. Left retrocardiac opacity representing
atelectasis and small left-sided pleural effusion.
.
CHEST (PORTABLE AP) [**2123-1-24**] 12:59 PM
A single AP view of the chest is obtained [**2123-1-24**] at 13:10 hours
and compared with the prior day's radiograph. There has been an
increase in the left-sided pleural effusion since the prior day.
There appears to be a new small right- sided pleural effusion.
Increased retrocardiac density on the left side is consistent
with combination of fluid together with likely
atelectasis/airspace disease. Mild prominence of the
interstitial markings is visible.
IMPRESSION: Increasing left-sided pleural effusion. Small new
right-sided pleural effusion. Increased interstitial markings.
Subsegmental atelectasis/airspace disease both bases, more
marked on the left side.
.
CHEST (PORTABLE AP) [**2123-1-25**] 7:08 AM
Cardiac and mediastinal contours are stable in appearance.
Perihilar haziness has slightly worsened, as well as a bilateral
pattern of interstitial opacities. Confluent opacity in left
retrocardiac region adjacent to a small-to-moderate left
effusion is unchanged. Small right pleural effusion has slightly
increased.
.
LABS:
.
[**2123-1-28**] 05:23AM BLOOD WBC-34.3* RBC-3.96* Hgb-10.8* Hct-33.5*
MCV-84 MCH-27.2 MCHC-32.2 RDW-18.2* Plt Ct-325
[**2123-1-27**] 03:55AM BLOOD WBC-27.7* RBC-3.99* Hgb-10.8* Hct-34.0*
MCV-85 MCH-27.0 MCHC-31.7 RDW-18.6* Plt Ct-315
[**2123-1-26**] 09:17AM BLOOD WBC-23.8* RBC-4.02* Hgb-11.0* Hct-33.8*
MCV-84 MCH-27.5 MCHC-32.6 RDW-18.7* Plt Ct-297
[**2123-1-25**] 10:44AM BLOOD WBC-18.8* RBC-3.62* Hgb-9.8* Hct-31.1*
MCV-86 MCH-27.1 MCHC-31.5 RDW-19.0* Plt Ct-263
[**2123-1-24**] 05:35AM BLOOD WBC-17.0*# RBC-3.54* Hgb-9.6* Hct-30.4*
MCV-86 MCH-27.1 MCHC-31.6 RDW-19.1* Plt Ct-230
[**2123-1-23**] 04:00AM BLOOD WBC-42.1* RBC-4.62# Hgb-12.1# Hct-39.8#
MCV-86 MCH-26.2* MCHC-30.4* RDW-19.2* Plt Ct-356
[**2123-1-23**] 04:00AM BLOOD Neuts-15* Bands-6* Lymphs-77* Monos-1*
Eos-0 Baso-1 Atyps-0 Metas-0 Myelos-0
[**2123-1-28**] 05:23AM BLOOD Plt Ct-325
[**2123-1-28**] 05:23AM BLOOD PT-20.0* PTT-25.1 INR(PT)-1.9*
[**2123-1-27**] 03:55AM BLOOD Plt Ct-315
[**2123-1-27**] 03:55AM BLOOD PT-20.0* PTT-25.9 INR(PT)-1.9*
[**2123-1-26**] 09:17AM BLOOD Plt Ct-297
[**2123-1-26**] 09:17AM BLOOD PT-20.3* PTT-26.8 INR(PT)-2.0*
[**2123-1-25**] 03:47PM BLOOD PT-21.5* PTT-27.3 INR(PT)-2.1*
[**2123-1-25**] 10:44AM BLOOD Plt Ct-263
[**2123-1-24**] 05:35AM BLOOD Plt Ct-230
[**2123-1-24**] 05:35AM BLOOD PT-20.1* PTT-27.2 INR(PT)-1.9*
[**2123-1-23**] 04:00AM BLOOD Plt Ct-356
[**2123-1-23**] 04:00AM BLOOD PT-18.0* PTT-23.6 INR(PT)-1.7*
[**2123-1-28**] 05:23AM BLOOD Glucose-181* UreaN-26* Creat-0.7 Na-143
K-4.0 Cl-103 HCO3-34* AnGap-10
[**2123-1-27**] 03:55AM BLOOD Glucose-143* UreaN-28* Creat-0.9 Na-147*
K-3.2* Cl-102 HCO3-36* AnGap-12
[**2123-1-26**] 09:17AM BLOOD Glucose-89 UreaN-25* Creat-0.8 Na-144
K-3.6 Cl-103 HCO3-33* AnGap-12
[**2123-1-25**] 10:44AM BLOOD Glucose-183* UreaN-29* Creat-0.7 Na-141
K-4.2 Cl-106 HCO3-29 AnGap-10
[**2123-1-24**] 05:35AM BLOOD Glucose-143* UreaN-35* Creat-0.9 Na-142
K-4.2 Cl-107 HCO3-26 AnGap-13
[**2123-1-23**] 04:00AM BLOOD Glucose-254* UreaN-35* Creat-0.8 Na-140
K-7.4* Cl-104 HCO3-24 AnGap-19
[**2123-1-23**] 04:00AM BLOOD CK(CPK)-79
[**2123-1-23**] 04:00AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2123-1-28**] 05:23AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.3
[**2123-1-27**] 03:55AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.1
[**2123-1-26**] 09:17AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.2
[**2123-1-25**] 10:44AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.3
[**2123-1-24**] 05:35AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.3
[**2123-1-23**] 04:00AM BLOOD Calcium-9.4 Phos-5.2* Mg-2.6
[**2123-1-23**] 04:00AM BLOOD Digoxin-1.2
[**2123-1-23**] 06:50AM BLOOD Type-ART Temp-37.8 O2 Flow-10 pO2-414*
pCO2-48* pH-7.34* calTCO2-27 Base XS-0 Intubat-NOT INTUBA
[**2123-1-23**] 06:50AM BLOOD Glucose-206* Lactate-2.4* K-4.9
[**2123-1-23**] 04:21AM BLOOD Lactate-2.6*
.
MICRO:
.
URINE CULTURE (Final [**2123-1-25**]):
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
2ND ISOLATE. <10,000 organisms/ml.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ 2 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- R
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ <=1 S
.
Stool cx: Negative for C.diff
Brief Hospital Course:
87 F h/o CVA with previous trach, still G-tube'ed, now presents
with witnessed aspiration with respiratory distress.
.
# Respiratory distress: presumed secondary to aspiration
pneumonitis and fluid overload. WBC difficult to interpret given
h/o CLL. CXR with atelectasis and small left-sided pleural
effusion. She was initially treated empirically with
vancomycin/Zosyn for coverage of MRSA (residence at [**Hospital1 5595**]) and
aspiration. Once patient able to adequately take p.o.
medications, she was switched to Levaquin. However, patient's
sputum cx showed only contamination and she remained afebrile.
Therefore, antibiotics were discontinued [**1-26**] and she continued
to do well. There was a component of fluid overload based on
bibasilar crackles and + JVD. Patient was diuresed with 20 IV
Lasix as needed which seemed to improve her respiratory status.
However, she continued to be somewhat tachypneic and use
accessory muscles (particularly abdominal) but this may be her
baseline as she appears comfortable and now speaks in complete
sentences.
.
# Gastrointestinal symptoms: given that she came from HRRA,
which is known to currently have an outbreak of Norovirus. Did
not stool for first 2 days of admission. However, on day 3,
began having loose stools. C. diff has been negative x5.
C.diff toxin B and norovirus are both pending. She received
supportive care including hydration as needed and loperamide
added for symptomatic relief.
.
# Atrial fibrillation: ventricular response in 120s, likely
secondary to current pulmonary process. Continued digoxin with
dig level 1.2 Metoprolol increased to 50mg po TID. Continued
warfarin with frequent INR checks.
.
# Diabetes: Initially just on sliding scale insulin. Long
acting insulin was started after initiation of tube feeds.
.
# Cardiac: No known history of CAD, though multiple vascular
risk factors and prior CVAs suggest that she almost certainly
does have CAD. Lateral ECG changes are similar to prior. Nausea
is likely secondary gastroenteritis. Overall low suspicion for
active ischemia. Cardiac enzymes negative. She was continued on
lisinopril, simvastatin, metoprolol. Unclear why she is not an
aspirin although she is anticoagulated on Coumadin.
.
# CLL: no acute issues
.
# FEN: Tube feeds restarted per nursing home schedule and well
tolerated. Electrolytes were repleted as needed.
.
# Prophylaxis: Anticoagulated on warfarin. Received PPI. Bowel
regimen held given diarrhea.
.
# Code status: Documented full code and confirmed with family.
Medications on Admission:
Baclofen 5 [**Hospital1 **]
Prilosec 40 QD
Flagyl 500 Q8
Insulin
- RISS
- Lantus 5 QD
Aranesp 60 QMo
Dig 0.125 QD
Lisinopril 20 QD
Metoprolol 100 [**Hospital1 **]
MVI
Zocor 40 QHS
Trazodone 25 QHS
Venlafaxine 37.5 QD
Coumadin 3 QD
Tylenol 650 PRN
Albuterol PRN
Dulcolax PRN
Atrovent PRN
Mucomyst Inh PRN
Compazine PRN
Discharge Medications:
1. Baclofen 10 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2 times a day).
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Insulin Lispro (Human) 100 unit/mL Solution [**Last Name (STitle) **]: As directed
Subcutaneous ASDIR (AS DIRECTED): [**11-24**] for NPO.
4. Digoxin 125 mcg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
5. Lisinopril 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID
(3 times a day).
7. Simvastatin 40 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO DAILY
(Daily).
8. Venlafaxine 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO QAM (once a
day (in the morning)).
9. Venlafaxine 25 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO QPM (once a day
(in the evening)).
10. Tylenol 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO every six (6)
hours as needed for pain.
11. Albuterol Sulfate 0.083 % Solution [**Month/Day (2) **]: Two (2) puffs
Inhalation Q3-4H (Every 3 to 4 Hours) as needed for shortness of
breath or wheezing.
12. Ipratropium Bromide 0.02 % Solution [**Month/Day (2) **]: One (1) treatment
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
13. Multi-Vitamin Tablet [**Month/Day (2) **]: One (1) Tablet PO once a day.
14. Insulin Glargine 100 unit/mL Solution [**Month/Day (2) **]: Five (5) units
Subcutaneous at bedtime: Half for NPO.
15. Aranesp 60 mcg/mL Solution [**Month/Day (2) **]: Sixty (60) units Injection
qMonday.
16. Loperamide 2 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO QID (4 times
a day) as needed for loose stool.
17. Warfarin 1 mg Tablet [**Month/Day (2) **]: Three (3) Tablet PO DAILY (Daily):
Continue to have your INR checked and your coumadin level
evaluated by MD.
18. Lidocaine HCl 2 % Gel [**Month/Day (2) **]: One (1) Appl Mucous membrane TID
(3 times a day) as needed for rectal tube.
19. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
20. Zolpidem 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
21. Compazine 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO every six (6)
hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2732**] & Retirement Home - [**Location (un) 55**]
Discharge Diagnosis:
Primary diagnosis:
- Aspiration
- Diarrhea
Secondary diagnosis:
- Hypertension
- Hyperlipidemia
- Atrial fibrillation on coumadin
- Boarderline diabetes
- Chronic lymphocytic leukemia
Discharge Condition:
Stable, afebrile, respiratory status stable
Discharge Instructions:
Take all medications as directed.
Go to all follow up appointments.
If you develop fever, chills, chest pain, shortness of breath or
any other symptom that concerns you, call you doctor or go to
the emergency room.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 142**]
Follow up norovirus, c. diff toxin B, Urine culture results
|
[
"5070",
"5180",
"5119",
"42731",
"4241",
"4019",
"2724",
"25000",
"V5861"
] |
Admission Date: [**2116-7-27**] Discharge Date: [**2116-8-8**]
Date of Birth: [**2038-6-5**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
headache and vision loss
Major Surgical or Invasive Procedure:
AVM embolization
History of Present Illness:
70RHW h/o LE edema and [**Hospital **] transferred from OSH after
presenting with sudden onset of right frontal HA and loss of
left
peripheral vision at yoga earlier today, found on OSH NCHCT to
have a right occipital IPH.
Pt reports being at yoga class earlier today and having sudden
onset of a right frontal sharp, nonthrobbing headache [**6-6**]
associated with loss of her peripheral vision on the left. She
doesn't recall doing any particular strenuous motion when it
occurred. She's been doing yoga for 6 mos.
She drove home although she admits to only being able to hear
the
"whoosh" of and not actually being able to see the oncoming cars
driving by her on her left. She turned into her driveway and
crashed into the left side of her garage; subsequently backed
up,
adjusted and parked her car in the garage.
She then proceeded to call her son who came over immediately and
called 911. She was taken to an OSH where BP 133/80 in NSR and
plt 256. No record of coags were sent with her. NCHCT showed a
right occipital hemorrhage. She was given Decadron 10mg x1 and
transferred to [**Hospital1 18**] ED. En route, she developed nausea and
vomited [**2-29**] carsickness per pt. Repeat NCHCT here in ED is
unchanged. Reports that headache no [**4-6**] with no improvement of
vision, no residual nausea or vomiting.
No recent med changes, stressors or changes from her routine.
Denies prior headaches, diplopia, hearing changes, dysphagia,
dysarthria, weakness, numbness/tingling, vertigo,
incoordination,
urine or bowel incontinence, fall, cough, diarrhea.
Reports that she gets hot flashes like fevers in the morning or
when coming back to bed from the BR which she's had since her
50s
that have been unchanged.
Past Medical History:
LE edema
Hyperchol
GERD
phlebitis in her legs b/l
Denies bleeding/clotting disorder
Social History:
Quit tob 30 yrs ago, smoked from age 17 to 40 ~[**1-29**] PPD. Occ
ETOH. Retired office manager
Family History:
Brother had surgery for a brain aneurysm. Sister has
valvular/ht dz and is s/p pacer. Brother s/p splenectomy and
required transfusions
Physical Exam:
T- 95.5 BP- 129/78 HR- 88 RR- 16 99 O2Sat 2L
Gen: Lying in bed, NAD
HEENT: NC/AT, moist oral mucosa
Neck: supple, no carotid or vertebral bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema, varicosities in legs L>R
Neurologic examination:
MS:
General: alert, awake, normal affect
Orientation: oriented to person, place, date, situation
Attention: +MOYbw. Follows simple/complex commands. No alien
hand. Reads 2nd half of sentence "on the radio last night"
"top"
"ma" despite moving paper to right of center when [**Location (un) 1131**].
Speech/[**Doctor Last Name **]: fluent w/o paraphasic errors; comprehension,
repetition, naming and [**Location (un) 1131**] intact
Memory: Registers [**3-30**] and Recalls [**3-30**] at 5 min
L/R confusion: Touches left thumb to right ear
Praxis: Able to brush teeth
CN:
I: not tested
II,III: Dense left homonymous hemianopsia, PERRL 4mm to 2mm,
fundi without obvious abnormality
III,IV,V: EOMI, no ptosis. No nystagmus
V: sensation intact V1-V3 to LT
VII: facial strength intact/symmetrical
VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**6-1**] bilaterally
XII: tongue protrudes midline, no dysarthria
Motor: Normal bulk and tone; no tremor, asterixis or myoclonus.
No pronator drift.
Delt [**Hospital1 **] Tri WE FE Grip
C5 C6 C7 C6 C7 C8/T1
L 5 5 5 5 5 5
R 5 5 5 5 5 5
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
L 5 5 5 5 5 5
R 5 5 5 5 5 5
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 2 2 2 2 2 Flexor
R 2 2 2 2 2 Flexor
Sensation: Intact to light touch, cold, vibration and
proprioception throughout. No extinction to DSS.
Coordination: finger-nose-finger normal, heel to shin normal,
RAMs normal.
Gait: Narrow based but mildly unsteady due to VFF.
Romberg: Negative
Pertinent Results:
[**2116-7-31**] 06:30AM BLOOD WBC-5.4 RBC-4.17* Hgb-12.2 Hct-35.5*
MCV-85 MCH-29.2 MCHC-34.3 RDW-13.2 Plt Ct-279
[**2116-7-28**] 05:50AM BLOOD WBC-9.8 RBC-4.71 Hgb-13.8 Hct-39.7 MCV-84
MCH-29.4 MCHC-34.9 RDW-13.3 Plt Ct-319
[**2116-7-27**] 07:50PM BLOOD WBC-7.3 RBC-4.61 Hgb-13.2 Hct-38.2 MCV-83
MCH-28.7 MCHC-34.6 RDW-13.5 Plt Ct-295
[**2116-7-31**] 06:30AM BLOOD Plt Ct-279
[**2116-7-31**] 06:30AM BLOOD PT-13.0 PTT-28.9 INR(PT)-1.1
[**2116-7-28**] 05:50AM BLOOD Plt Ct-319
[**2116-7-28**] 05:50AM BLOOD PT-13.0 PTT-27.4 INR(PT)-1.1
[**2116-7-27**] 07:50PM BLOOD Plt Ct-295
[**2116-7-27**] 07:50PM BLOOD PT-12.7 PTT-26.9 INR(PT)-1.1
[**2116-7-30**] 08:00PM BLOOD ESR-22*
[**2116-7-30**] 08:00PM BLOOD ACA IgG-6.2 ACA IgM-8.8
[**2116-7-31**] 06:30AM BLOOD Glucose-89 UreaN-14 Creat-1.0 Na-140
K-3.5 Cl-104 HCO3-26 AnGap-14
[**2116-7-28**] 05:50AM BLOOD Glucose-142* UreaN-12 Creat-0.9 Na-139
K-3.7 Cl-103 HCO3-25 AnGap-15
[**2116-7-27**] 07:50PM BLOOD Glucose-123* UreaN-12 Creat-0.9 Na-139
K-3.4 Cl-104 HCO3-25 AnGap-13
[**2116-7-27**] 07:50PM BLOOD ALT-13 AST-19 AlkPhos-73 TotBili-0.5
[**2116-7-27**] 07:50PM BLOOD Lipase-33
[**2116-7-31**] 06:30AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.0
[**2116-7-28**] 05:50AM BLOOD Calcium-9.2 Phos-3.6# Mg-2.0 Cholest-179
[**2116-7-27**] 07:50PM BLOOD Calcium-9.1 Phos-1.6* Mg-2.0
[**2116-7-30**] 08:00PM BLOOD Homocys-15.0*
[**2116-7-28**] 05:50AM BLOOD Triglyc-61 HDL-58 CHOL/HD-3.1 LDLcalc-109
[**2116-8-8**]: WBC 6.1 RBC 3.41* hgb 10.0* HCT 29.1* MCV 85 MCH 29.4
MCHC 34.5 RDW 13.5 Platelet 287
CT head w/o contrast [**7-27**]:
There is a 4 x 1.6 cm parenchymal hemorrhage in the right
posterior parietal lobe with surrounding vasogenic edema without
significant mass effect or shift of normally midline structures.
There are no other foci of hemorrhage or intraventricular
extension. The ventricles and sulci are normal in size and
configuration. The osseous and soft tissue structures are
unremarkable.
MRI brain [**2116-7-28**]:
1. No significant change in the size of the acute hematoma in
the right
occipital lobe compared to the CT scan done a few hours earlier.
Mild
surrounding edema, unchanged.
2. Peripheral enhancement noted in the margins of the hematoma;
a few vessels are identified within the periphery on the TOF
angiogram, which is somewhat technically limited. Hence a
vascular abnormality cannot be definitively excluded as a cause
of the hematoma. It is unclear if these vessels are abnormal or
represent normal vessels displaced by the hematoma itself. A
follow study after resolution of the hematoma including the area
of interest or a conventional diagnostic angiogram can be
performed for better assessment of any vascular lesions. If a
followup MR angiogram is considered, please mention on the
indication to include the area of abnormality completely on the
MR angiogram.
CTA [**2116-7-28**]:
No change in appearance of right occipital parenchymal
hemorrhage
with a small amount of surrounding vasogenic edema. A few
prominent vessels are seen in the vicinity of the hematoma;
however, exact etiology of the lesion remains uncertain as it
could be obscured in the setting of acute hematoma. Differential
diagnosis continues to include vascular malformation such as
AVM, or cavernoma, hypertensive hemorrhage, as well as
underlying mass lesion cannot be excluded. Followup MRI after
resolution of the hematoma is recommended to evaluate its
underlying cause.
CT Head [**2116-8-5**]:
There is a slight increase in the right occipital parenchymal
hemorrhage with surrounding area of vasogenic edema. This may be
in part due to recent intervention and placement of embolization
coils. There is no new midline shift, effacement of the
quadrigeminal cistern or hydrocephalus. There is no acute
vascular territorial infarct.
Brief Hospital Course:
This 78 yo F was at yoga class when she experienced the sudden
onset of headache and then subsequent loss of left sided vision.
Brain imaging revealed a right occipital bleed. Subsequent MRA
and CT-angio were equivocal about the source of bleed. However,
subsequent conventional angiography revealed the presence of an
AVM. The pt underwent formal visual field testing [**2116-8-3**] with
Dr. [**Last Name (STitle) **] where she was found to have a left homonymous
hemianopsia. She was transferred to the neurointerventional
service for embolization of the AVM on [**2116-8-5**]. She tolerated the
procedure well. Her right groin was closely observed and there
were no post-embolization complications. Her neuro exam was
also closely observed and remained stable to the time of
discharge.
Neuro exam prior to discharge:
She is alert and awake, orientated x 3. She continues to have a
left homonymous hemianopsia. Her strengh and sensation is full
throughout. Reflexes are full and symmetric.
Medications on Admission:
HCTZ 25mg QD
Fosamax
Ca with D 600mg QD
MVI
Lipitor 10mg QD
Protonix 40mg QD
Vitamin C 500mg QD
Aspirin 81mg QD
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
2. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-29**]
Tablets PO Q6H (every 6 hours) as needed for headache: Do not
take more than 6 tablets per day.
Disp:*20 Tablet(s)* Refills:*0*
3. Outpatient Medications
Please continue to take all outpatient medications as previously
prescribed by your doctor.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right occipital intracerebral hemorrhage
Right occipital AVM
Left homonymous hemianopsia
Discharge Condition:
good
Discharge Instructions:
Discharge Instructions:
-Continue all other medications you were taking before surgery,
unless otherwise directed
-You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What activities you can and cannot do:
-When you go home, you may walk and go up and down stairs
-You may shower (let the soapy water run over groin incision,
rinse and pat dry)
-Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
-No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
-After 1 week, you may resume sexual activity
-After 1 week, gradually increase your activities and distance
walked as you can tolerate
-No driving until you are no longer taking pain medications
What to report to office:
-Changes in vision (loss of vision, blurring, double vision,
half vision)
-Slurring of speech or difficulty finding correct words to use
-Severe headache or worsening headache not controlled by pain
medication
-A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
-Trouble swallowing, breathing, or talking
-Numbness, coldness or pain in lower extremities
-Temperature greater than 101.5F for 24 hours
-New or increased drainage from incision or white, yellow or
green drainage from incisions
-Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes.
- If bleeding DOES STOP, call our office.
- If bleeding DOES NOT STOP, call 911 for transfer to closest
Emergency Room
Please take Dilantin as prescribed for a total of 3 months.
Followup Instructions:
Follow-Up Appointments:
Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **], to be seen in 4 weeks.
You will need a CT scan of the brain without contrast for this
appointment.
Please follow up with your PMD in [**1-29**] weeks.
Please obtain follow up MRI in [**7-5**] weeks and thereafter schedule
an appointment with Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 2574**].
Completed by:[**2116-8-8**]
|
[
"2720",
"53081"
] |
Admission Date: [**2124-8-19**] Discharge Date: [**2124-8-24**]
Date of Birth: [**2089-2-8**] Sex: M
Service: MEDICINE
Allergies:
Ergotamine / Codeine
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
elevated LFTs, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 65730**] is a 35yo M w/PMHx of depression, PTSD, anxiety, panic
attacks, prior IVDU who presented to the [**Hospital1 18**] ED on [**2124-8-18**]
with fever, nausea and vomiting since [**8-11**]. He was initially
admitted to the floor with elevated LFTs and on repeat check
today they had doubled with an ALT [**2059**], AST [**2119**], Alk Phos 231,
LDH 1242, T. Bili 4.0. Liver was consulted and recommended NAC
gtt which prompted his MICU transfer.
.
The patient states his symptoms first began friday [**8-11**] with
nausea, bilious vomiting, and later fevers. His temp 3 days PTA
was 104 degrees for which he presented to the ED and had an LP
done which showed 3 WBCs in tube 4, 485 RBCs, 20% polys, 50%
lymphocytes, 20% monos. Gram stain was negative. He was sent
home and returned the following day for worsening nausea,
vomiting and headache. Vomiting is bilious, no blood or coffee
grounds. He adamantly denies ingestions such as tylenol,
methanol, ethylene glycol. He has taken Excedrin 2tab qday for
the past week due to morning headaches. He denies alcohol use or
any drug use. Last used prescription drugs 4 years ago, now
transitioned to Methadone. He denies HIV or HCV although per
PCP, [**Name10 (NameIs) **] has a prior HCV Ab positive test.
.
In the ED on [**8-18**], initial vs were: T 100.6 P 79 BP 112/61 R 16
O2 sat. 97% on RA. The patient then spiked to a temp of 101. He
was anxious on arrival and refused a rectal exam. He received
tylenol, ibuprofen for headache and fever, 2mg ativan for
anxiety and compazine for nausea and got caffeine IV for post-LP
headache. Blood cultures were sent.
.
On the floor, he complained of headache for which he received
Ibuprofen, anxiety for which he received 1mg PO Ativan, and
nausea for which he received Zofran. He has not vomitted in 12
hours.
.
Currently, he continues to complain of headache and anxiety.
Feels itchy.
Past Medical History:
#. s/p Left thyroidectomy/parathyroidectomy
#. h/o +PPD with -CXR
- never treated with IH
#. Migraines
- patient reports he has very rarely had migraines in his past,
too few in frequency to compare to current symptoms
#. Depression
#. PTSD
#. Panic attacks
- patient has had many psychiatric hospitalizations, >7
with history of multiple prior suicide attempts
Social History:
Supported himself through high school and college, completed
nursing degree and has license to practice in several states.
Has sex with men and says he always uses a condom (greater than
20 partners and no risky activity). Has had 1 sexual partner in
the past 2 years which was a 1 night stand with protection and
person was HIV negative. Previous partner of 12 years was HIV
negative. Last HIV test was [**3-30**]. H/o domestic abuse (physical,
verbal). H/o homelessness, in shelters. h/o sexual assault.
Lives in [**Location 86**] by himself. Does not smoke but smoked 1 pack a
day for 8 years, the last time was a few months ago. No ETOH but
was an occasional drinker in the past. Denies IVDU but has h/o
drug abuse, including oxycontin, dilaudid and others (says
always used clean needles, never shared). Last used heroine 11
years ago, was sober for a while, then relapsed with Oxycontin.
Sober now for 4 years, on Methadone.
Family History:
Does not know family history, adopted.
Physical Exam:
Vitals: T: 98.1 BP: 135/81 P: 76 R: 16 O2: 100% RA
General: Alert, in some distress, anxious-appearing but
breathing comfortably
HEENT: Slight scleral icterus, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft but firm due to patient's inability to relax for
exam. Diffuse tenderness throughout without peritoneal signs.
tenderness greatest in epigastric area. Unable to appreciate
liver borders due to patient discomfort. +BS.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: multiple papular lesions of anterior chest, shoulders and
scattered along back. Some excoriations along legs.
Non-vesicular in nature.
Pertinent Results:
[**2124-8-18**] 11:30PM BLOOD WBC-2.6* RBC-4.09* Hgb-12.6* Hct-36.1*
MCV-88 MCH-30.8 MCHC-34.9 RDW-13.0 Plt Ct-194
[**2124-8-19**] 08:56PM BLOOD WBC-3.1* RBC-4.48* Hgb-13.0* Hct-40.4
MCV-90 MCH-29.1 MCHC-32.3 RDW-12.9 Plt Ct-165
[**2124-8-24**] 05:00AM BLOOD WBC-6.6 RBC-4.02* Hgb-11.8* Hct-36.5*
MCV-91 MCH-29.2 MCHC-32.2 RDW-14.3 Plt Ct-283
[**2124-8-18**] 11:30PM BLOOD Neuts-68.9 Lymphs-22.7 Monos-3.8 Eos-2.9
Baso-1.7
[**2124-8-20**] 12:13PM BLOOD Neuts-23* Bands-0 Lymphs-51* Monos-10
Eos-2 Baso-0 Atyps-14* Metas-0 Myelos-0
[**2124-8-21**] 05:00AM BLOOD Neuts-11* Bands-0 Lymphs-67* Monos-4
Eos-1 Baso-0 Atyps-17* Metas-0 Myelos-0
[**2124-8-23**] 05:05AM BLOOD Neuts-26.2* Bands-0 Lymphs-66.8*
Monos-4.0 Eos-2.2 Baso-0.6
[**2124-8-19**] 01:00PM BLOOD PT-17.0* PTT-33.3 INR(PT)-1.5*
[**2124-8-24**] 05:00AM BLOOD PT-11.3 PTT-28.6 INR(PT)-0.9
[**2124-8-18**] 11:30PM BLOOD Glucose-106* UreaN-14 Creat-0.8 Na-138
K-3.3 Cl-103 HCO3-24 AnGap-14
[**2124-8-24**] 05:00AM BLOOD Glucose-95 UreaN-7 Creat-0.5 Na-140 K-4.2
Cl-107 HCO3-26 AnGap-11
[**2124-8-18**] 11:30PM BLOOD ALT-1327* AST-1265* LD(LDH)-888*
CK(CPK)-260* AlkPhos-232* TotBili-2.8* DirBili-2.4* IndBili-0.4
[**2124-8-19**] 01:00PM BLOOD ALT-[**2059**]* AST-[**2119**]* LD(LDH)-1242*
AlkPhos-231* TotBili-4.0*
[**2124-8-19**] 08:56PM BLOOD ALT-2303* AST-2297* LD(LDH)-1250*
CK(CPK)-171 AlkPhos-227* TotBili-4.4*
[**2124-8-20**] 03:32AM BLOOD ALT-2372* AST-2177* LD(LDH)-1174*
AlkPhos-212* TotBili-4.4*
[**2124-8-20**] 12:13PM BLOOD ALT-[**2061**]* AST-1512* LD(LDH)-558*
AlkPhos-198* TotBili-4.7*
[**2124-8-21**] 12:40AM BLOOD ALT-1770* AST-1018* LD(LDH)-364*
AlkPhos-219* TotBili-4.6*
[**2124-8-21**] 05:00AM BLOOD ALT-1586* AST-776* LD(LDH)-298*
AlkPhos-207* TotBili-3.9*
[**2124-8-21**] 03:30PM BLOOD ALT-1471* AST-595* LD(LDH)-299*
AlkPhos-227* TotBili-4.0*
[**2124-8-22**] 05:05AM BLOOD ALT-1117* AST-341* AlkPhos-223*
TotBili-3.0*
[**2124-8-19**] 01:00PM BLOOD calTIBC-321 Ferritn-464* TRF-247
[**2124-8-19**] 02:07PM BLOOD TSH-3.6
[**2124-8-19**] 02:07PM BLOOD HBsAb-POSITIVE HBcAb-NEGATIVE
[**2124-8-18**] 11:30PM BLOOD HBsAg-NEGATIVE IgM HBc-NEGATIVE IgM
HAV-NEGATIVE
[**2124-8-19**] 01:00PM BLOOD Smooth-NEGATIVE
[**2124-8-19**] 02:07PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2124-8-19**] 02:07PM BLOOD PEP-NO SPECIFI IgG-869
[**2124-8-19**] 01:00PM BLOOD HIV Ab-NEGATIVE
[**2124-8-19**] 08:56PM BLOOD Ethanol-NEG
[**2124-8-18**] 11:30PM BLOOD ASA-4 Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
[**2124-8-21**] 03:30PM BLOOD HCV Ab-POSITIVE*
[**2124-8-18**] 11:36PM BLOOD Lactate-1.2
[**2124-8-19**] 09:55PM BLOOD Lactate-2.3*
Brief Hospital Course:
# Elevated LFTs/Hepatitis: Mr. [**Known lastname 65730**] presented with 7 day
history of nausea, bilious vomitting and 3 day history of fever.
He had presented to the ED and sent home after negative LP,
normal CXR, normal CT/CTA head. He then returned for worsening
nausea, vomitting and headache. On admission, his ALT and AST
were determined to be 1327 and 1265, respectively. He was
started on IVF and serology was sent for Hepatitis A,B and C,
CMV, EBV, [**Doctor First Name **], Anti-smooth muscle. Additionally, ceruloplasm
and alpha-1 anti-trypsin were sent. Patient was also determined
to be leukopenic. Out of concern for possible HSV hepatitis,
patient was started on IV acyclovir pending HSV serology. On
serial LFT's, his transaminitis worsened and patient was
transferred to MICU for initiation of NAC even though there was
no reported tylenol abuse. In the MICU, ALT/AST peaked at
2372/2297 and patient was clinically stable. He was
transferred to [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] for continued management within 24
hours of admission to the ICU. On the floor, patient was
continued on NAC for cumulative total 20 hours. Acyclovir was
continued until day of discharge. ultimately, all serology was
negative except for HCV antibody with viral load 10.1 million.
HSV IgM was negative, as were CMV, HIV and EBV serology. Repeat
CBC with differentials were monitored and showed a recovery of
leukopenia shortly after admission. Additionally, the
differential showed many atypical lymphocytes which were thought
to indicate likely viral etiology to hepatitis. Abdominal pain
and nausea improved over the hospital course. Mr. [**Known lastname 65730**] was
hemodynamically stable, tolerating PO and ambulating on day of
discharge. He was instructed to follow-up with his PCP at
[**Name9 (PRE) 778**] for management of his HCV.
.
# Anxiety: Due to acute hepatitis, patient's ativan and
clonazepam were held throughout the admission. A decreased
5-day supply of ativan was prescribed to patient on discharge
with instructions to have prescription refilled through PCP.
.
# Headache: Was likely secondary to post-LP given lack of
photophobia, neck stiffness, negative neuro signs. Patient
required pain medication prn for headache and abdominal pain.
.
# History of multi-drug abuse: continued patient on methadone
regimen (confirmed with clinic) and gave patient last-dose
letter on discharge.
.
# Depression: Held Wellbutrin for potential hepatotoxicity.
Restarted on discharge for 5-days with follow-up at PCP
[**Name Initial (PRE) 1988**].
Medications on Admission:
Ativan 1mg TID to QID
Welbutrin 100mg PO BID
Methadone 60mg PO qday
PRN Excedrin
Discharge Medications:
1. Methadone 10 mg Tablet Sig: Six (6) Tablet PO DAILY (Daily).
2. Wellbutrin SR 100 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day for 5 days.
Disp:*10 Tablet Sustained Release(s)* Refills:*0*
3. Ativan 1 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
4. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Transdermal
every seventy-two (72) hours as needed for motion sickness.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Acute Hepatitis
Secondary: Chronic Hepatitis secondary to Hepatitis C infection
Discharge Condition:
Good. Hemodynamically stable with normal vitals. Ambulating
without difficulty.
Discharge Instructions:
You were admitted to the hospital because of your fever, nausea,
vomiting, and abdominal pain. You were found to have extensive
inflammation of your liver. Your labs were monitored and trended
toward normal. You were treated with an antiviral medication in
case the inflammation was related to a herpes infection. To be
cautious, you were also treated for tylenol toxicity even though
your tylenol level was normal. Tests for herpes were negative so
the anti-viral was stopped.
There are many other viruses that may have caused this
inflammation. Unfortunately, there are no good medications for
viruses other than herpes although your liver should repair
itself as long as you refrain from any unneccessary medications.
You should refrain from taking any more than 2g tylenol daily.
You should not drink alcohol.
Many tests were sent and were negative but your hepatitis C
returned positive and appeared to be causing active
inflammation. This is unlikely to be the cause of your current
condition although it could be contributing to the severity.
Please call 911 or return to the ED should you experience
fevers, chills, nausea, vomiting, worsening abdominal pain,
bleeding, shortness of breath or any other concerning symptoms.
Followup Instructions:
Please follow up at [**Hospital1 778**] ([**Street Address(2) 6421**]) with [**Doctor First Name 58656**]
(Nurse Practitioner who works with Dr [**Last Name (STitle) 6420**] on [**8-29**] at 11:10 am.
|
[
"V1582"
] |
Admission Date: [**2119-6-11**] Discharge Date: [**2119-6-16**]
Date of Birth: [**2038-7-18**] Sex: M
Service: MEDICINE
Allergies:
Dilantin / Gentamicin
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Fever, hypoxia, mental status changes
Major Surgical or Invasive Procedure:
Central line
Heel debridement
History of Present Illness:
The patient is an 80 year old male s/p subarachnoid hemorrhage 3
years ago with L ICA aneurysm s/p coiling, h/o hydrocephalus s/p
VP shunt revision in [**2119-1-26**] by Dr. [**Last Name (STitle) **], DMII and dementia
who presented to the ED on [**2119-6-11**] as a transfer from [**Hospital 4199**]
Hospital who received the patient from his nursing home after
being found with hypoxia sat'ing in the 70s-80s with tachypnea
and hypotension BP 80/p with unresponsiveness with a fever of
105.5.
.
The patient had been evaluated in the [**Hospital1 18**] ER on [**2119-6-10**] for
mental status changes and was seen by neurosurgery who felt that
his symptoms were secondary to a UTI. He had a CT and plain film
of his head that showed no discontinuity of the LP shunt with no
acute intracranial hemorrhage and slight increase in size of the
3rd and 4th ventricles. He was discharged to his nursing home
with cipro for a UTI.
.
At [**Last Name (un) 4199**], the patient was found to be febrile to 105.5, P 134,
RR 46, BP 109/88, 92% on a 100% NRB. ABG 7.44/36/98. Labs
remarkable for K 5.0, BS 276, Cr 1.4. WBC 12, Hct 41. Troponin I
0.06, CKMB 0.8.
.
The patient was given clindamycin and avelox 400 mg IV for ?
pneumonia/UTI and transferred to [**Hospital1 18**]. His temp on arrival was
100.4, HR 105, bp 116/46, RR 28, 94% - 100% on NRB. He received
a total of 6 liters IVF in the ED after his BP dropped from 116
to 74/48. A left femoral line was placed and the patient was
placed on dopamine 10 mcg. Lactate 3.5. He was given ceftriaxone
2 gm IV and vancomycin 1 gm for presumed ?meningitis.
.
Neurosurgery evaluated the patient in the ED and felt that his
symptoms were not neurologic or secondary to meningitis. LP was
not felt to be necessary.
.
Repeat CT head performed with results still pending. CXR
initially showed NAD but on repeat showed ?RLL infiltrate.
Repeat UA mildly positive with 6-10 WBC, 0 epithelial cells.
.
The patient was maintained on a 100% NRB and a femoral line was
placed with multiple unsuccessful attempts at central access
through IJ/subclavian. Transferred to MICU for sepsis management
on dopamine 10 mcg.
.
ROS:
.
Unable to obtain given mental status.
Past Medical History:
PMH:
.
- DM2, diet controlled, does not require insulin
- HTN, was recently started on lisinopril, but daughter d/c'd
- A-fib
- Carotid stenosis
- Gout
- COPD
- thyroid cancer s/p resection, iodine irradiation, placement of
vocal cord stent
- SAH w/ L ICA aneurysm s/p coiling 3 years ago
- hydrocephalus s/p VP shunt
- DVT s/p IVC filter, placed 3y ago
- mitral valve repair with history of endocarditis, [**2106**]
- dementia :patient has NO seizure d/o, per daughter he was
started on valproic acid for abnormal behavior in the setting of
UTI
several years ago
.
Past Surgical History:
.
Mitral valve repair [**2106**]
IVC filter
thyroid cancer resection with vocal cord stent [**1-27**]
Left ICA coiling
VP shunt with revision [**2-1**]
Social History:
Lives at [**Location **]. Wife deceased recently from lung cancer. Previously
had been independent. Daughters in area. Has smoked [**12-27**] ppd
since age 12, quit recently.
Family History:
- Mother died of cerebral hemorrhage in her 50's
- No h/o cancer or heart disease
Physical Exam:
PE:
.
Tc = 98.0 Tm = 105.5 P = 85 BP = 115/52 (105-145) RR = 18 100%
O2 sat on 100% NRB
.
Gen - Somnolent, arousable with voice, opens eyes, does not
follow commands, speaking words
HEENT - Pinpoint pupils bilaterally, anicteric
Heart - RRR, no M/R/G
Lungs - Bilateral rhonchi
Abdomen - Soft, NT, ND + BS
Ext - RLE heel with serosanguinous pus, tender
Back - Stage II sacral decubitus x 3 small 1-2 cm
Skin - As above
Neuro - Does not follow commands, pinpoint pupils bilaterally,
opens eyes, names daughters appropriately, answers few questions
Pertinent Results:
Admission labs
[**2119-6-10**] 12:15PM BLOOD WBC-7.6 RBC-5.07 Hgb-12.6* Hct-38.5*
MCV-76* MCH-24.9* MCHC-32.8 RDW-15.0 Plt Ct-165
[**2119-6-10**] 12:15PM BLOOD Neuts-71.9* Lymphs-18.3 Monos-5.6 Eos-3.9
Baso-0.3
[**2119-6-10**] 12:15PM BLOOD PT-13.1 PTT-26.7 INR(PT)-1.1
[**2119-6-10**] 12:15PM BLOOD Glucose-178* UreaN-22* Creat-1.1 Na-143
K-4.3 Cl-105 HCO3-29 AnGap-13
[**2119-6-10**] 12:15PM BLOOD CK(CPK)-33*
[**2119-6-10**] 12:15PM BLOOD cTropnT-<0.01
[**2119-6-11**] 07:50AM BLOOD CK-MB-4 cTropnT-<0.01
[**2119-6-11**] 12:01PM BLOOD CK-MB-6 cTropnT-0.02*
[**2119-6-11**] 05:30AM BLOOD Albumin-2.8* Calcium-7.7* Phos-4.7*
Mg-1.8
[**2119-6-15**] 05:35AM BLOOD calTIBC-218* Ferritn-86 TRF-168*
[**2119-6-11**] 07:50AM BLOOD Cortsol-20.3*
[**2119-6-11**] 12:01PM BLOOD Cortsol-19.3
[**2119-6-10**] 12:15PM BLOOD TSH-5.8*
[**2119-6-10**] 12:15PM BLOOD Valproa-49*
[**2119-6-11**] 05:38AM BLOOD Lactate-3.5*
[**2119-6-11**] 06:11AM BLOOD Lactate-1.3
Discharge labs:
[**2119-6-16**] 05:30AM COMPLETE BLOOD COUNT WBC 6.7 RBC4.01 Hgb10
Hct 29.1 MCV 73 RDW 15Plt Ct 152
RENAL & GLUCOSE Glucose 110 UreaN 18 Creat 1 Na 144 K 4.1 Cl
109 HCO3 24 AnGap 15
IMAGING:
CT head:
FINDINGS: Since previous examination, there is minimal to
slightly increased size of the third ventricle. The lateral
ventricles are generally unchanged. There is no evidence of
acute hemorrhage or shift of normally midline structures. The
appearance of regions of old infarct and periventricular white
matter hypoattenuation are unchanged. The patient is again noted
to be status post aneurysmal coiling in the left supraclinoid
region.
IMPRESSION: No evidence of acute intracranial hemorrhage. There
is unchanged to slight increase in size of the third ventricle
without change within the lateral ventricles. The
ventriculostomy catheter is unchanged in position. There is also
the appearance of mild increase in dilatation of the fourth
ventricle.
CTA chest:
CT OF THE CHEST WITH IV CONTRAST: The central airways are patent
to the segmental levels, bilaterally. An NG tube is noted, its
tip is excluded. The pulmonary artery is patent without filling
defects to suggest pulmonary embolism. Again noted, extensive
atherosclerotic changes involving the aorta. Unchanged anterior
mediastinal mass. There is a conglomeration of lymph nodes in
the mediastinum, which are borderline enlarged and unchanged
when compared to the prior study dated [**2116-6-16**]. Since
prior exam, the pleural effusions have resolved. Coronary artery
calcifications are noted. The heart is normal in size. The
patient is status post mitral valve replacement.
Bilateral dependent airspace consolidation likely represents
aspiration pneumonia, less likely atelectasis. There are
scattered hazy nodules within the right middle lobe and right
upper and right lower lobe, the largest one measuring 7 mm in
the right lower lobe.
IMPRESSION:
1. No evidence of PE.
2. Bilateral dependent airspace consolidation likely represents
aspiration pneumonia, less likely atelectasis.
3. Unchanged right anterior mediastinal mass likely residual
thyroid.
4. Borderline enlarged lymph nodes in the mediastinum, and
unchanged when compared to prior study.
5. Coronary artery disease.
6. Scattered hazy nodules within the right lung, the largest one
measuring 7 mm in the right lower lobe. Followup in six months
is recommended.
CXR:
[**2119-6-13**]
CHEST, AP UPRIGHT: Comparison is made to two days earlier. The
patient is status post sternotomy and mitral valve replacement.
Cardiac and mediastinal contours are unchanged. There is a dense
left lower lobe consolidation, as well as patchy but extensive
consolidations in the mid right lung and both lower lung fields,
markedly progressed since the prior study. There is no definite
effusion or pneumothorax.
IMPRESSION: Considerable progression of bilateral pulmonary
opacities, most consistent with multifocal pneumonia or
aspiration.
CXR
[**6-11**]:
FINDINGS: The cardiac and mediastinal silhouette is unchanged.
There has been interval increase in perihilar haziness. Compared
to the film from two hours prior there is a new right lower lobe
infiltrate. The pulmonary vasculature is engorged compared to
the earlier examination. There is left basilar atelectasis.
Multiple median sternotomy wires overlie the midline of the
thorax. A ventriculoperitoneal shunt remains in position. There
is no pneumothorax. An IVC filter projects over the right upper
quadrant of the abdomen.
IMPRESSION: New right lower lobe infiltrate. Increased vascular
engorgement. Findings concerning for pulmonary edema. Clinical
correlation is recommended. No pneumothorax.
Brief Hospital Course:
# Impression: The patient is an 80 year old male with a history
of dementia, SAH with left ICA aneurysm s/p coiling c/b
hydrocephalus s/p VP shunt, PAF, dementia, DMII who presents
from his nursing home with hypoxia, fever, hypotension and right
lower extremity pus at heel concerning for sepsis now on
dopamine/vancomycin and zosyn day 1.
Change in mental status: Patient was admitted initially with
change in mental status thought to be due to to infection.
There was initial concern for infection of his VP shunt, but
felt unlikely per neurosurgery. He then became hypotensive and
was transferred to the MICU. While there he was on a dopamine
drip and broad spectrum antibioticss as well as IV fluids.
Mental status rapidly improved with treatment of infection as
well as restarting his outpatient dementia medications.
Infection: Initially had fever to 105.5 in the [**Last Name (un) 4199**] ER, had
leukocytosis on admission. Likely infection source was either
pneumonia or his right heel ulcer. These were covered with
vancomycin/ zosyn and then transitioned to levofloxacin and
clindamycin (changed to ceftriaxone and clindamycin, given that
heel ulcer was growing MSSA resistant to levofloxacin and had
recently finished a course of levofloxacin). It was thought
that meningitis was even more unlikely given the rapid
resolution. Moreover the right heel had frank pus initially
and grew MSSA.
Aspiration pneumonia: found to be initially hypoxic and had
evolving chest x-ray that showed signs of aspiration.
Additionally he had signs of aspriation seen. He was finally
treated with ceftriaxone and clindamycin and should continue a
10 day course (7 more days).
Dementia Has baseline dementia. Initially with mental status
changes medications were held. But restarted with improvment to
baseline depakote, concerta, razadyne for now until mental
status improves.
Anemia Had hematocrit drop with aggressive IV fluids and
remains stable. However, found to have low ferritin and was
started on ferrous gluconate
Renal insufficiency Initially elevated creatnine that improved
with IV fluids.
DMII Does not take insulin at home and reportedly
"diet-controlled". Was briefly on insulin gtt. And now is
controlled with insulin sliding scale. Will continue while
infected but may not need it after his infection is cleared and
may again be diet controlled.
Hypothyroid
- Follow up as outpatient as TSH elevated to 5.3. Continue
levothyroxine for now at 188 mcg and recheck TSH after acute
infection resolves for follow up in [**12-27**] weeks.
History of paryoxysmal atrial fibrillation
- Currently in not in afib. Also not on ASA/coumadin with a
history of intracranial bleed.
#Code - FULL -confirmed with family
Daughter [**Name (NI) 2411**] is HCP
Medications on Admission:
Levothyroxine 188 mcg PO QD
Recently d/c'd - levo/flagyl for ?aspiration pneumonia last date
[**5-29**] and [**2119-6-2**] respectively
Concerta 27 mg PO QD
Valproic acid for dementia 250 mg PO QD
Cipro 500 mg (1st day [**2119-6-10**] for UTI)
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection Q8H (every 8 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
7. CONCERTA 27 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily).
8. Galantamine 4 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
9. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) for 7 days.
10. Cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO twice a day
for 7 days.
11. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Insulin Regular Human 100 unit/mL Solution Sig: as dir
Injection four times a day: sliding scale.
13. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Sepsis likely secondary to heel infection
aspiration pneumonia
.
Dementia
Hypertension
Diabetes
history of SAH
history of endocarditis
Discharge Condition:
improved BP, afebrile
Discharge Instructions:
You were admitted with infection in your heel and lungs. You
were treated with antibiotics.
You should continue your antibiotics for at least 10 days and
call the doctor if you have any fever, chills, chest pain,
shortness of breath or vomiting, worsening mental status, or low
oxygen or any other concerning symptoms.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **] [**12-27**] weeks
[**Last Name (LF) **],[**First Name3 (LF) **] S. [**Telephone/Fax (1) 1144**]
Podiatry follow up in 1 week: [**2122-6-19**]:50 AM
F/u CT chest for lung nodules
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
"0389",
"5070",
"78552",
"496",
"99592",
"25000",
"4019"
] |
Admission Date: [**2116-9-21**] Discharge Date: [**2116-9-27**]
Date of Birth: [**2067-10-16**] Sex: M
Service: CSURG
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
CAD sp MI
Major Surgical or Invasive Procedure:
sp CABG X 4 [**9-23**]
History of Present Illness:
48 yo M w/ hx of CAD sp MI and stent to diagonal [**2112**] and stent
to PTL in [**6-27**] p/w recurrent anginal symptoms. + stress test.
Cath showed 3 vessel disease.
Past Medical History:
as above, CRI, GERD, HTN, hyperlipidemia, renal calculi
Social History:
Tobacco: 60 yr pack hx; quit in [**2112**]. ETOH: 2 beers per day
Family History:
F: MI @ 39 yr
M: MI @ 69 yr
Physical Exam:
Ht: 6 ft 3 in
Wt: 255 lb
RRR, No M, G, R
CTAB
obese, soft, NT
1 + Fem B. 2 + rad, DP, PT B.
Pertinent Results:
[**2116-9-21**] 12:30PM GLUCOSE-96 UREA N-20 CREAT-1.1 SODIUM-142
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13
[**2116-9-21**] 12:30PM ALT(SGPT)-19 AST(SGOT)-17 CK(CPK)-138 ALK
PHOS-28* TOT BILI-0.4
[**2116-9-21**] 12:30PM CK-MB-3 cTropnT-<0.01
[**2116-9-21**] 12:30PM ALBUMIN-4.2
[**2116-9-21**] 12:30PM WBC-5.7 RBC-4.36* HGB-12.8* HCT-36.0* MCV-83
MCH-29.3 MCHC-35.5* RDW-13.3
[**2116-9-21**] 12:30PM PLT COUNT-203
[**2116-9-21**] 12:30PM PT-14.3* INR(PT)-1.3
Brief Hospital Course:
PT underwent a CABG X 4 [**9-23**]. Pt was transferred to the CSRU in
a stable condition. Pt required minimal blood products post
operatively.
Hospital course was remarkable for transient post operative
Atrial fibrillation. BBlocker was given post operatively and
amiodarone was added. Conversion to sinus rhythm occurred in
less than 24 hrs, so anticoagulation was never started.
Pt's chest tubes and paing wires were DC'd without problem.
Pt's foley came out and the pt was voiding on his own upon DC.
The pt tolerated a cardiac diet and pain was well controlled on
PO pain medications. Pt was cleared by PT for home and the pt
was DC'd with VNA.
Pt was DC'd on the below medications.
Medications on Admission:
nexium 40 PO [**Month/Year (2) **], folic acid PO [**Month/Year (2) **], tricor 160 PO [**Month/Year (2) **],
lopressor 75 PO [**Month/Year (2) **], Norvasc 5 PO [**Last Name (LF) **], [**First Name3 (LF) **] 81 PO [**First Name3 (LF) **]', Plavix
75 PO [**First Name3 (LF) **]
Discharge Medications:
1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*14 Capsule, Sustained Release(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*75 Tablet(s)* Refills:*0*
8. Fenofibrate Micronized 160 mg Tablet Sig: One (1) Tablet PO
qd ().
Disp:*30 Tablet(s)* Refills:*2*
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QD (once a day).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
10. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*2*
11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
12. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Community VNA
Discharge Diagnosis:
Coronary artery disease
Chronic renal insufficiency
Gastroesophageal reflux disease
Hypertension
Hyperlipidemia
Discharge Condition:
stable
Discharge Instructions:
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Also go to the ER if your wound becomes red, swollen, warm, or
produces pus.
You may remove your dressings 2 days after your surgery if they
were not removed in the hospital.
Follow up with your PCP regarding new medication called lipitor.
You will need intermittent lab tests while taking this
medication.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No heavy lifting or exertion for at least 6 weeks.
Please refrain from driving yourself for one month and/or while
taking pain medications.
You may resume your regular diet as tolerated.
You may take showers (no baths) after your dressings have been
removed from your wounds.
Followup Instructions:
Call and schedule a follow up appointment in [**2-27**] weeks with Dr.
[**Last Name (STitle) **] ([**Telephone/Fax (1) 1504**]).
Please follow up with PCP [**Last Name (NamePattern4) **] [**1-28**] weeks.
Completed by:[**2116-9-28**]
|
[
"41401",
"4019",
"53081",
"2724",
"412"
] |
Admission Date: [**2116-4-17**] Discharge Date: [**2116-5-1**]
Date of Birth: [**2048-7-15**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Aldactone
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
intubation
tracheostomy
PEG
History of Present Illness:
67 yo F with COPD, CHF, MVR, CRI secondary to renovascular
disease was reffered to ED for abnormal labs.
.
She came in today for routine labs and hct noted to be 18.8
(from 31.7 one month ago). Has noted increased fatigue and SOB.
She says that she noted BRBPR on toilet paper few days ago that
she attributed to hemorrhoids. She says that when she walked in
triage RN noted that she had bright red blood running down her
leg (not documented). She denies melena but says that her stools
are dark at baseline due to iron.
.
She had EGD and colonoscopy done [**5-16**] which showed gastritis and
duodenitis, and 3 small colonic polyps (felt to be hyperplastic)
which were not biopsied due to her need for anticoagulation and
f/u colonscopy was recommended. She was treated with protonix,
and clarithro/amox/protonix for positive Hpylori.
.
In ED VS 98.1, 72, 112/25, 13, 100%2LNC--> Hct noted to be 18.8.
Rectal: black guaiac positive stool. NG lavage was clear but
without bilious return. Her sBP dropped down to 60s and she was
admitted to the ICU for further w/u and treatment.
.
Past Medical History:
PAST MEDICAL HISTORY:
1. Rheumatic heart disease status post mitral valve prolapse
x2 with a mechanical valve.
2. COPD with a FEV1 of 0.6.
3. CHF with an EF of 20-30% by echocardiogram [**2114-5-15**].
4. History of AFib status post ablation/pacer.
5. Peripheral vascular disease, history of aortofemoral
bypass.
6. CAD with a previous one-vessel disease by cath in '[**06**].
7. History of pulmonary hypertension.
8. History of bilateral renal artery stenosis.
9. Chronic renal insufficiency with baseline creatinine of
1.6-2.4.
10. History of secondary hyperparathyroidism.
11. Status post cholecystectomy
.MEDS:
Coumadin 5
Digoxin 0.0625qd
Colace 100bid
Lasix 40qd
Lisinopril 2.5qd
Toprol XL 25qd
Advair
Spiniva
Lipitor 10
Protonix 40BID
FeSo4
Epogen
.
All: Bactrim, Aldactone
Social History:
Patient quit smoking 1 month ago, prior half pack per day, 50
pack year history. Denies any alcohol use. She lives with her
husband and son in a single floor apartment.
Family History:
Noncontributory.
Physical Exam:
PE VS 77/56 70
GEN: NAD
HEENT:PERRL, EOMI, Dry MMM
LUNGS:CTAB
COR:RRR, deformed surgical chest
ABD:S, NT/ ND +BS
EXT:WWP, no edema, +1 DP
RECTAL: black stool, OB positive, external hemorrhoids,
non-bleeding
Pertinent Results:
Labs on admission to ICU
[**2116-4-17**] 12:20AM BLOOD WBC-4.7 RBC-1.89* Hgb-5.8* Hct-18.8*
MCV-100* MCH-31.0 MCHC-31.1 RDW-17.6* Plt Ct-184
[**2116-4-16**] 02:17PM BLOOD WBC-5.0 RBC-1.97*# Hgb-5.9*# Hct-19.6*#
MCV-100* MCH-29.8 MCHC-29.9* RDW-17.4* Plt Ct-192
[**2116-4-17**] 12:20AM BLOOD Neuts-71.2* Bands-0 Lymphs-18.7 Monos-6.9
Eos-2.9 Baso-0.4
[**2116-4-17**] 12:20AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
[**2116-4-17**] 12:20AM BLOOD PT-23.3* PTT-34.8 INR(PT)-3.4
[**2116-4-17**] 12:20AM BLOOD Plt Smr-NORMAL Plt Ct-184
[**2116-4-16**] 02:17PM BLOOD Plt Ct-192
[**2116-4-16**] 02:17PM BLOOD PT-21.5* INR(PT)-2.9
[**2116-4-17**] 12:20AM BLOOD Glucose-96 UreaN-91* Creat-3.5* Na-143
K-4.9 Cl-110* HCO3-23 AnGap-15
[**2116-4-16**] 02:17PM BLOOD UreaN-94* Creat-3.7*# Na-140 K-4.6 Cl-106
HCO3-24 AnGap-15
[**2116-4-16**] 02:17PM BLOOD ALT-11 AST-15
[**2116-4-17**] 04:40AM BLOOD CK(CPK)-58
[**2116-4-17**] 04:40AM BLOOD CK-MB-NotDone cTropnT-0.33*
[**2116-4-17**] 01:25PM BLOOD CK-MB-NotDone cTropnT-0.24*
[**2116-4-17**] 09:44PM BLOOD CK-MB-NotDone cTropnT-0.27*
[**2116-4-17**] 04:40AM BLOOD Calcium-7.8* Phos-5.6*# Mg-1.8
[**2116-4-16**] 02:17PM BLOOD TSH-4.9*
[**2116-4-18**] 01:58AM BLOOD Triglyc-133 HDL-34 CHOL/HD-3.7 LDLcalc-64
[**2116-4-22**] 01:50AM BLOOD PTH-183*
[**2116-4-17**] 04:40AM BLOOD Cortsol-20.4*
[**2116-4-17**] 04:41AM BLOOD Type-ART Temp-35.4 Rates-16/ Tidal V-500
PEEP-5 FiO2-100 pO2-190* pCO2-46* pH-7.22* calHCO3-20* Base
XS--8 AADO2-485 REQ O2-81 -ASSIST/CON Intubat-INTUBATED
[**2116-4-17**] 05:50AM BLOOD Type-ART Temp-36.0 pO2-228* pCO2-43
pH-7.25* calHCO3-20* Base XS--8 Intubat-INTUBATED
[**2116-4-17**] 04:41AM BLOOD Lactate-1.4
[**2116-4-17**] 10:12AM BLOOD Lactate-1.0
[**2116-4-17**] 04:41AM BLOOD freeCa-1.03*
[**2116-4-17**] 01:30PM BLOOD freeCa-1.10*
Labs on discharge
[**2116-4-30**] 11:59AM BLOOD Hct-32.3*
[**2116-4-30**] 04:05AM BLOOD WBC-6.9 RBC-3.56* Hgb-10.4* Hct-32.0*
MCV-90 MCH-29.1 MCHC-32.3 RDW-16.2* Plt Ct-180
[**2116-4-29**] 03:32PM BLOOD WBC-6.2 RBC-3.23* Hgb-9.4* Hct-28.8*
MCV-89 MCH-29.1 MCHC-32.6 RDW-16.1* Plt Ct-192
[**2116-4-27**] 03:18AM BLOOD WBC-7.1 RBC-3.36* Hgb-9.7* Hct-30.4*
MCV-90 MCH-28.8 MCHC-31.9 RDW-16.5* Plt Ct-151
[**2116-4-30**] 11:59AM BLOOD PT-16.1* PTT-92.1* INR(PT)-1.6
[**2116-4-30**] 06:30AM BLOOD PTT-91.7*
[**2116-4-30**] 04:05AM BLOOD Plt Ct-180
[**2116-4-30**] 04:05AM BLOOD Glucose-109* UreaN-85* Creat-2.9* Na-139
K-4.4 Cl-112* HCO3-17* AnGap-14
[**2116-4-29**] 03:32PM BLOOD Glucose-117* UreaN-87* Creat-2.8* Na-140
K-4.5 Cl-113* HCO3-19* AnGap-13
[**2116-4-30**] 04:05AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.4
[**2116-4-29**] 03:32PM BLOOD Calcium-8.9 Phos-3.2 Mg-2.3
[**2116-4-30**] 04:18AM BLOOD Type-ART Temp-36.3 Rates-20/ Tidal V-500
PEEP-5 FiO2-50 pO2-175* pCO2-29* pH-7.39 calHCO3-18* Base XS--5
-ASSIST/CON Intubat-INTUBATED
Brief Hospital Course:
1. GIbleed: The initial concern was of upper GI (pylorus) vs.
lower GI source. SHe underwent EGD that did not reveal a source
of bleed. on [**4-17**]-5. Surgery and interventional readiology was
consulted. She was intubated initially for airway protection as
she had COPD and required sedation for comfort. She continued to
have bleeding and required numerous (around 6 units of pRBC and
6 units of FFP for coumadin reversal). She subsequently
underwent angiography to find the source of bleeding that
revealed 1) an irregular abdominal aorta with a patent
aorto-bifemoral bypass graft. There is complete occlusion of the
left renal artery.2)cclusion of the inferior mesenteric artery.
3) Selective celiac arteriogram revealed irregularity within the
gastroduodenal artery and tortuosity of the splenic artery. No
vascular abnormality or pseudoaneurysm was identified.4)
Selective superior mesenteric arteriography revealed a focal
moderate stenosis just distal to its origin with collateral
filling of the left colic and superior hemorrhoidal arteries via
the middle colic and SMA branches. There was no evidence of
active extravasation nor vascular abnormality identified.THe SMA
stenosis was stented but no evidence of bleed was found. Over
the next day (3/5-6), She continued to experience dropping Hct
and underwent abdominal CT to rule out retroperitoneal bleed.
The abdominal Ct was negative for any such bleed. As her
hematocrit stabilized on [**4-14**]. She was restarted on heparin
for her mitral valve replacement. She has had continued trace
guiac positive stool throughout her hospital stay, but she never
had another episode of new GI bleed.
2. MVR: She underwent emergent reversal of anticoagulation with
FFP given acute GI bleed and hypotension on admission. She was
restarted on heparin on [**4-21**] after her hematocrit stabilized. Her
heparin was held again on [**4-28**] briefly for tracheostomy and PEG
tube placement. Her heparin was restarted on [**4-28**]. Her coumadin
was restarted on [**4-30**].
.
3. Respiratory: Severe COPD (FEV1 0.6) and CHF (EF 20%). She was
initally intubated for airway protection and given need for
aggresive volume resuscitation and EGD.
She was attempted to wean from the ventilator on [**2122-4-23**], but
this was unsuccessful as she was likely to experience
respiratory muscle deconditioning, fluid overload and baseline
severe COPD. Disucssion was made with the family. She was tried
briefly on BiPAP and given lasix and nebulizer but she failed to
respond and was reintubated on [**4-24**] and given her likely need
for slow wean from ventilation . She underwent tracheostomy
placement on [**4-29**]. She is deemed to need slow wean from vent.
She will go to a vent rehab facility for weaning.
.
4. Renal: She experienced acute on chronic renal failure likely
due to volume depletion on admission with creatine bump to
3.5-3.7. This was improved with aggresive volume resuscitation
and blood transfusion. Her lisinopril was held. She was also
started on dopamine drip briefly during her hospital stay along
with lasix drip to help her mobilized her fluid given her CHF
status. Her kidney responded by increasing urine outpt and
decreasing creatine. She was followed by renal consult on this
admission. She was deemed to be not hemodilaysis candidate on
this admission as her kidney suffered an acute event. However,
if her renal function does not improve in the near future, she
will need an evaluation for hemodialysis. She is also to
continued on regular epogen shot for chronic renal insuffiency
.
5. CHF: EF 20%. Monitor volume status with fluid resusciation.
Her lasix was held this admission
.
6. CAD: h/o 1vd by cath in 95. Her aspiring was held given her
GI bleed. Her beta-blocker was held given hypotension.
Transfuse for hct >28.
7. Infectious disease- She developed fever and grew gram
negative rod that speciated to be pan-sensitive serratia during
this admission . SHe was treated with 10 day course of
ceftazidime. She also grew MRSA from her sputum at the same
time. She was also treated with 10 day course of vancomycin. She
was placed on MRSA precaution during this hospitalization.
.
8. FEN. She was initially held on po diet given her GI bleed and
procedures. She was later started on Tube feed during
intubation. She is getting tube feed through her PEG tube on
discharge.
.
8. Access:She received an right IJ and Left a-line during this
admission for fluid resucitation and intensive blood pressure
monitoring.
.
.
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
2. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
3. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-16**]
Puffs Inhalation Q6H (every 6 hours) as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
7. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
8. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
9. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
10. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO DAILY (Daily).
11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every
4 to 6 hours) as needed.
12. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. Fludrocortisone Acetate 0.1 mg Tablet Sig: 0.5 Tablet PO
DAILY (Daily) for 7 days.
14. Metoclopramide 5 mg IV Q6H
15. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution
Sig: One (1) Intravenous ASDIR (AS DIRECTED): please aim for
PTT goal of 60-80 while pt is being transitioned to coumadin.
16. Fentanyl Citrate 25-100 mcg IV Q4H:PRN
17. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime:
please check INR daily and adjust to goal INR 2.5-3.5.
18. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day.
19. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): 2 unit for FS 150-200: 4 unit for
FS 201-250; 6 unit for FS 251-300; 8 unit for FS 301-350; 10
unit for FS 351-400; 10 unit for FS 410 or greater and call
house officer.
20. Morphine Sulfate 2 mg/mL Syringe Sig: One (1) Injection Q4H
(every 4 hours) as needed.
21. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
CHF
Chronic renal insuffiency
COPD
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:1.5L
PLease check INR daily and adjust coumadin to INR 2.5-3.5.
Coumadin to start on [**5-1**] with 2mg coumadin. Please stop heparin
once INR is therapeutic for a couple of days.
Please do continous bladder irrigation and decrease frequency as
needed to q2 then q4 and monitor for signs of blood clots and
urine output. PLease call hospital if much increased hematuria,
but hematuria should resolved over next several days.
Please check patient creatine daily and forward to facility
doctor as pt may need hemodialysis in the future (no indication
for hemodilaysis right now) stable creat @ 2.9. PLease have
facility doctor arrange for renal clinic followup at [**Hospital1 18**] if
persistent high creatine as they may need to start hemodialysis
in the future
Pt is adrenal insuffient. Pt will need to be on 10 prednisone
and 0.1 fludrocortisone indefinitely.
Followup Instructions:
please make appointment to see you primary doctor in 2 weeks
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"5070",
"496",
"40391",
"51881",
"5990",
"5849",
"2762",
"2760",
"41401",
"4168",
"2859"
] |
Admission Date: [**2145-5-22**] Discharge Date: [**2145-6-5**]
Date of Birth: [**2069-5-23**] Sex: F
Service: Medicine/[**Doctor Last Name 11541**]
HISTORY OF PRESENT ILLNESS: This is a 76-year-old female
with a history of coronary artery disease status post
coronary artery bypass grafting and mitral valve replacement
with a porcine valve, atrial fibrillation, history of rapid
ventricular response, diabetes mellitus, MRSA endocarditis,
left atrial thrombus originally admitted to [**Hospital1 346**] on [**2145-5-22**] complaining of
headache, nausea, vomiting and increased INR originally 11.2
to 15.6 on day of admission after being on Coumadin for left
atrial thrombus and porcine mitral valve. The patient had a
head CT which showed a large intraparenchymal hemorrhage in
the cerebellum with mass effect. The patient was originally
admitted to the neurosurgical intensive care unit after she
had a posterior fossa craniotomy for resection of left
cerebellar hemorrhage and areas of necrotic cerebellum.
HOSPITAL COURSE: 1. Neurology: The patient was status post
cerebellar hemorrhage thought to be originally an embolic
event with hemorrhagic conversion due to elevated INR. As
mentioned above the patient underwent posterior fossa
craniotomy for resection of the hemorrhage as well as for
resection of areas of necrotic cerebellum. The patient did
well postoperatively and had a small amount of drainage from
her wound on postoperative day number three which was treated
with additional sutures. No drains remained in place. From
a neurological perspective, the patient had follow-up head CT
scans on [**5-24**] and [**5-26**] which showed no evidence of
hydrocephalus, no enlarging collection and no new infarct.
The patient's neurologic examination had been relatively
stable with the patient's inability to speak, but ability to
move all extremities and intermittently follow commands as
well as opening eyes to voice.
The patient was restarted on her anticoagulation when she was
transferred to the medical floor as her underlying etiology
of the stroke was thought to be embolic in nature, and given
her porcine mitral valve, it is important that she would be
anticoagulated to prevent further strokes even though the
risk of anticoagulation was also stroke.
The patient initially had some improvement in her
neurological examination, however it was intermittent in
nature. The patient underwent extensive further testing with
repeat head CT that again showed no evidence of hydrocephalus
or new stroke on [**6-3**]. The patient also had an MRI and
MRA of the head to further evaluate for microthrombi. The
study was somewhat limited secondary to staples causing
artifact, however there was no acute cortical infarct, with
normal ventricle size and configuration. The patient did
have chronic microvascular ischemia and infarction that was
old. There was good flow to most of the intracerebral to
cranial arteries. The patient also underwent EEG and the
report is still pending at the time of this dictation.
2. Infectious disease: The patient initially had positive
blood cultures on [**5-21**] which grew out two of two bottles
of MRSA. Given that the patient had just completed a full
six-week course of IV vancomycin, two weeks of gentamicin,
and four-and-a-half weeks of Rifampin on prior admission for
MRSA endocarditis, it was thought that potential left atrial
thrombus was seated with bacteria which may have represented
the positive blood cultures. Subsequent blood cultures
during the hospitalization did not grow MRSA. The patient
was treated with vancomycin for presumed MRSA bacteremia and
continued to have a slightly elevated but stable white blood
cell count and remained afebrile.
The patient was also thought to have a pneumonia given her
large right pleural effusion status post intubation x 2 while
on the neurosurgical intensive care unit. The patient was
treated with a [**8-19**] day course of Zosyn IV for this.
3. Pulmonary: The patient initially had a clear chest x-ray
on admission however subsequently developed bilateral pleural
effusions, right greater than left. The right pleural
effusion was tapped and about 1.4 liters of fluid were
removed which were transudative and thought to be secondary
to her overall volume overload and anasarca on this
admission.
The patient was intubated x 2 and subsequently remained
extubated after [**2145-5-27**]. Pulmonary consultation was
obtained and the patient had drainage of right pleural
effusion as mentioned above and in addition was diuresed with
some improvement in her bilateral pleural effusions, however
they did recur but appeared to remain relatively stable.
4. Cardiovascular: The patient had a transesophageal
echocardiogram on [**2145-5-23**] that showed a 1.7 cm left
atrial thrombus, mild left ventricular hypertrophy, no masses
or vegetations on the aortic valve, 1+ aortic insufficiency,
mitral valve without vegetation, normal leaflet motion, 2+
tricuspid regurgitation. The patient did have left atrial
spontaneous echo contrast which was increased, with size of
the left atrial thrombus stable. The patient was initially
not anticoagulated given initial presentation with elevated
INR and stroke, however once she was medically stable she was
restarted on her anticoagulation with Coumadin only.
Ultimately she did become therapeutic on [**2145-6-8**] with
an INR of 2.2.
The patient has a history of atrial fibrillation and rapid
ventricular response. Initially she was rate controlled on
Toprol 150 mg q.i.d. and verapamil 80 mg p.o. t.i.d. and was
maintained on telemetry. She did have several episodes of
nonsustained ventricular tachycardia on her telemetry and
this was eventually discontinued after changing code status.
The patient did have several episodes of atrial fibrillation
with rapid ventricular response during her hospital course,
given difficulty with p.o. pain medications and absorption
issues as well as lack of response to IV Lopressor.
5. Fluids, electrolytes and nutrition: The patient had
nasogastric tube in place and was continued on her tube
feeds. She did have a low albumin however patient was unable
to be fully reevaluated by the speech and swallow service
given her overall lack of improvement in neurological status.
6. Acid base: The patient did have acid base abnormalities
which included initial PCO2 of around 41 which increased to
50 and then 58. The patient also had an elevated bicarbonate
and was thought to have a metabolic alkalosis with
respiratory acidosis that was not completely compensated.
This was partially due to her diuresis as well as perhaps
primary central component of decreased respiratory drive
secondary to her neurologic event.
The remainder of this hospital course will be dictated by Dr.
[**Last Name (STitle) **] [**Last Name (NamePattern4) **].
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Name8 (MD) 231**]
MEDQUIST36
D: [**2145-6-9**] 04:30
T: [**2145-6-15**] 10:24
JOB#: [**Job Number 11542**]
|
[
"4280",
"51881",
"42731",
"5070",
"2760"
] |
Admission Date: [**2124-3-3**] Discharge Date: [**2124-3-10**]
Service:
HISTORY OF PRESENT ILLNESS:
Patient is an 85-year-old male with a history of coronary
artery disease status post a recent two-vessel coronary
artery bypass graft on [**2124-2-17**], diabetes, hypertension, and
a recently noted right upper lobe lung nodule on prior CT
scan, who presents to the hospital on [**2124-3-3**] for wheezing
and dyspnea noted by VNA at home. He was initially admitted
to Surgical Intensive Care Unit when found to have a sodium
of 112 in the Emergency Department. He was also noted to
have bilateral crackles and evidence of some congestive heart
failure on initial chest x-ray.
Patient had previously had an uneventful postoperative course
on his prior admission except for some hyponatremia which had
been evaluated, admit by the medical consult team. Most
recently the patient's sodium had been 126 on [**2124-2-20**], and he had been sent home with a presumptive diagnosis
of chronic hyponatremia, possibly SIADH, and prescribed
sodium tablets. He was planned to followup for workup of his
right upper lobe lung nodule.
On [**2124-3-3**], he was noted to be dyspneic with some wheezing
at home per the VNA. The patient was admitted to the MICU
where he received 3% hypertonic saline. Was placed on 1
liter fluid restriction and given prn Lasix. Over the next
72 hours, his sodium improved from 112-126. The patient
denied feeling dyspneic or having other complaints such as
chest pain at home.
REVIEW OF SYSTEMS:
The patient had a cough for approximately one week productive
of some clear sputum. He denied any fevers, chills, or
sweats.
PAST MEDICAL HISTORY:
1. Type 2 diabetes.
2. Hypertension.
3. History of an enlarged prostate/prostate cancer, the
details of which the family was uncertain.
4. Lung nodule as noted on prior CT scan.
5. Hyponatremia as noted on prior admission. The family
states that patient has had a low sodium for approximately
four years.
6. Coronary artery disease status post two-vessel coronary
artery bypass graft on [**2124-2-17**].
7. Prior cerebrovascular accident found incidentally on head
CT scan.
8. Echocardiogram report. Pre-CABG was noted to have an
ejection fraction of 60-79% with 3-4+ MR. Cardiac
catheterization pre-CABG by report: Ejection fraction of
35%.
MEDICATIONS AT TIME OF TRANSFER TO THE MEDICAL SERVICE:
1. Hypertonic saline at 35 cc an hour.
2. Heparin subQ 5,000 units [**Hospital1 **].
3. Albuterol nebulizers.
4. Plavix 75 mg po q day.
5. Zantac 150 mg po q day.
6. Aspirin 325 mg po q day.
7. Colace 100 mg po q day.
8. Potassium chloride 20 mEq po bid.
9. Lopressor 12.5 mg po bid.
10. Percocet prn.
11. Sodium chloride tablets tid.
ALLERGIES:
1. Penicillin which causes hives.
2. Demerol which causes agitation.
SOCIAL HISTORY:
The patient has a history of tobacco, but has not smoked in
approximately 5-20 years except for the occasional cigar.
HOME MEDICATIONS:
1. Plavix 75 mg po q day.
2. Zantac 150 mg po q day.
3. Aspirin 325 mg po q day.
4. Colace 100 mg po q day.
5. Lasix 20 mg po q day.
6. Potassium chloride 20 mEq po bid.
7. Lopressor 12.5 mg po bid.
8. Percocet prn.
9. Glucotrol XL 5 mg po q day.
PHYSICAL EXAMINATION AT TIME OF TRANSFER FROM THE INTENSIVE
CARE UNIT:
Vitals: Temperature 99.5, pulse 72-83, blood pressure
109-132/44-50, respiratory rate 19-20, and pulse oximetry is
95-98% on 2 liters nasal cannula. General appearance: The
patient was awake, alert, jovial, and somewhat inappropriate
on his affect. HEENT: Pupils are equal, round, and reactive
to light. Extraocular movements are intact. Sclerae were
anicteric. Mucous membranes moist. Cardiovascular:
Regular, rate, and rhythm, normal S1, S2, no murmurs. Chest
is notable for healing sternotomy scars. Lungs: Scattered
wheezes bilaterally with decreased breath sounds at the bases
bilaterally. Abdomen is soft, nontender, nondistended with
active bowel sounds. Extremities show no edema. There is an
incision in the left groin secondary to prior intervention
with no obvious erythema or drainage.
LABORATORY STUDIES:
White blood count 8.2, hematocrit 27.5, platelets 598,000.
Sodium 126, potassium 4.9, chloride 97, glucose 79, magnesium
2.0, free calcium 1.11, cortisol 8.6.
Chest x-ray on [**2124-3-3**] showed an interval increase in the
patient's small right pleural effusion with adjacent
increased opacity in the posterior basilar segment of the
right lower lobe, question of atelectasis versus pneumonia.
There is also evidence of a small left pleural effusion.
From prior admission, chest CT scan on [**2124-2-16**] noted
bilateral small effusions with adjacent atelectasis, an
addition consolidation in the superior segment of the left
lower lobe, atelectasis, versus aspiration, versus pneumonia.
A 5 mm ill-defined density in the right upper lobe malignancy
versus scarring.
HOSPITAL COURSE:
1. Cardiovascular. The patient was status post recent
coronary artery bypass graft. His scars showed good evidence
of healing. He was maintained on his prior cardiac regimen
of aspirin, Lopressor. In the setting of some mild
congestive heart failure, he was also started on an ACE
inhibitor.
For congestive heart failure, the patient was continued on
his standing dose of po Lasix and given daily prn Lasix
typically 20-40 mg IV q day to keep the patient approximately
500 cc negative/day. Repeat chest x-ray after the patient
was transferred to the floor showed additional interval
increase in the patient's right sided pleural effusion which
was thought to be possibly associated with a right lower lobe
consolidation. Given the patient's history of right upper
lobe nodule on CT scan however, possibility of a malignant
effusion was also considered possible. Given the patient's
mild congestive heart failure, it was also felt that his
congestive heart failure was contributing to the effusion.
The patient was also continued on Plavix 75 mg po q day as
per CT Surgery recommendations during this hospitalization.
The patient was diuresed as noted above to keep him at least
500 to a liter negative each day. The patient had no
complaints of chest pain and actually denied shortness of
breath throughout his hospitalization. He was also followed
daily by the Cardiothoracic Surgery team and will be
following up with Dr. [**Last Name (STitle) 1537**] in the clinic shortly after his
discharge.
2. Pulmonary. As noted, the patient is noted to have an
interval increase in the size of a right sided pleural
effusion compared to last chest x-ray from prior admission
and even an additional interval increase during the first
several days of his hospitalization here. It was thought to
be secondary to congestive heart failure versus pneumonia
versus possible malignant effusion. The patient was
complaining of a dry cough. Was noted to have a low grade
temperature early on his hospitalization and chest x-ray did
suggest the possible associated right lower lobe
consolidation.
On [**2124-3-7**] the patient underwent thoracentesis which drained
approximately 1 liter of serous fluid slightly turbid
appearing. Fluid analysis was consistent with exudative
effusion. There were 1+ polys, no organisms noted on the
Gram stain, and bacterial cultures were negative. Fluid was
also sent for cytology, which was notable only for some
reactive mesothelial cells. Given the exudative nature of
the fluid, this is still possible to be a malignant origin,
and will be monitored for reaccumulation as an outpatient.
The Pleural Service followed the patient as an inpatient and
will review the case. Their feeling was that if the patient
had significant reaccumulation of fluid or became symptomatic
over the next several weeks, they would consider
reintervention such as pleuroscopy to look for evidence of
pleural malignant involvement and do biopsy if necessary.
The patient will be following with Dr. [**First Name4 (NamePattern1) 1151**] [**Last Name (NamePattern1) 2146**] in
Pulmonary as well.
For concern for pneumonia, the patient was treated with a
10-day course of Levaquin. The combination of some mild
diuresis and the removal of the fluid and antibiotic coverage
and/or a combination of the three resulted in improvement in
the patient's level of oxygenation as he was initially
sating in the low 90s on [**1-19**] liters on presentation to the
Medical Service. By the end of his hospitalization, he was
sating in the mid 90s on room air even with ambulation. He
was evaluated by physical therapy and thought to be safe to
go home.
3. Renal. The patient is noted to be hyponatremic to 112 on
admission. He had been notable to have some mild
hyponatremia which was thought to be chronic on the prior
admission to approximately 126-130. Family noted that the
patient had been noted to be hyponatremic at outside
hospitals for the past four years.
Given the presence of his right upper lobe lung nodule and
the results of his urine electrolytes, the patient was
thought to have SIADH. He was initially placed on hypertonic
saline and then on a strict fluid restriction, which resulted
in improvement in his sodium to approximately 130 by the time
of discharge. This appeared to be essentially his chronic
baseline. The patient will be continued on a fluid
restriction at home, and was not sent home on sodium tablets.
The drop in his sodium from 126-112 from the last
hospitalization may have been a combination of increased free
water intake versus pneumonia. The patient was also noted to
be hypocalcemic consistently during this hospitalization.
PTH level was checked and pending at the time of discharge.
Should the patient not have evidence of hypoparathyroidism,
other etiologies such as vitamin D deficiency can be
explored. The patient did not receive calcium
supplementation during this hospitalization.
4. Hematological. The patient is noted to have a low
hematocrit to approximately 27-28 which was not substantially
changed from his hematocrit at the time of his last
discharge. His prior baseline was not known. His iron
studies revealed a low iron, a mid to low TIBC, and an
elevated ferritin suggestive of anemia of chronic
inflammation or chronic disease. The patient was started on
daily iron supplements. He was also transfused 1 unit of
total red blood cells during this hospitalization which
raised his hematocrit to approximately 30.
5. Genitourinary. The patient with a history of some urinary
retention as per the family. Patient initially carried a
diagnosis per an old record of "prostate cancer" which had
been apparently worked up at an outside hospital in
[**Location (un) 17927**] several years ago. Patient's family noted that on
repeat evaluation he was noted not to have prostate cancer,
although it is unclear of the exact workup. The patient
initially had a Foley placed early in his hospitalization.
The patient accidentally traumatically removed the Foley with
results in hematuria.
Subsequently, the patient failed two voiding trials. Was
noted to have clear urine without any clots or evidence of
obstruction secondary to bleeding. The Urology Service was
curbsided, who felt that likely the patient had some baseline
urinary retention which had been exacerbated by Foley
placement. The patient was discharged home with a chronic
Foley catheter and with Urology followup. The VNA will be
coming in every day to help the patient with Foley changes.
The patient was also started on Flomax at the time of
discharge.
6. Endocrine. The patient was continued on his Glucotrol
with an insulin-sliding scale during his hospitalization.
His fingersticks remained within good control.
DISCHARGE DIAGNOSES:
1. Right upper lobe pulmonary nodule.
2. SIADH.
3. Right pleural effusion (exudative).
4. Pneumonia.
5. Urinary retention.
6. Congestive heart failure.
7. Coronary artery disease.
8. Anemia of chronic disease.
CONDITION ON DISCHARGE:
Stable.
DISCHARGE MEDICATIONS:
1. Zantac 150 mg po bid.
2. Plavix 75 mg po q day.
3. Lopressor 12.5 mg po bid.
4. Enteric coated aspirin 325 mg po q day.
5. Colace 100 mg po q day.
6. Glucotrol XL 5 mg po q day.
7. Levaquin 500 mg po q day x7 days to be completed on
[**2124-3-16**].
8. Lasix 40 mg po q day.
9. Iron sulfate 325 mg po tid.
10. Lisinopril 5 mg po q day.
11. Sublingual nitroglycerin 0.4 mg sublingual q five minutes
prn chest pain up three tablets in 15 minutes.
12. Flomax 0.4 mg po q day to be taken 30 minutes after a
meal.
DISCHARGE INSTRUCTIONS:
The patient will have VNA coming into his home several times
a week to assist with new medications and new medication
dosing. They will also assist with his Foley/leg bag prior
to followup with Urology. The patient should keep the Foley
in place constantly until Urology followup. VNA will also
assist with patient's 1500 cc daily fluid restriction. A
home safety evaluation will also be performed. The left
groin wound should be dressed with wet-to-dry normal saline
dressings with 2 x 2 gauze q day.
FOLLOW-UP APPOINTMENTS:
1. [**Hospital 191**] Clinic with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 39141**] on [**2124-3-15**] at 1:30 pm.
2. Pulmonary with Dr. [**Last Name (STitle) 2146**] on [**2124-3-23**] at 8:30 am
on the [**Location (un) **] of the [**Hospital Ward Name 23**] building.
3. Followup with Cardiac Surgery as previously scheduled with
Dr. [**Last Name (STitle) 1537**] on [**2124-3-14**] as previously scheduled.
4. Followup with Urology, Dr. [**Last Name (STitle) **]. The physician's office
will call the patient on Monday, [**2124-3-14**] to schedule an
appointment within the next week.
[**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern1) 17199**], M.D.
Dictated By:[**Last Name (NamePattern4) 18710**]
MEDQUIST36
D: [**2124-3-13**] 06:56
T: [**2124-3-13**] 07:04
JOB#: [**Job Number 23396**]
|
[
"4280",
"486",
"5119",
"25000"
] |
Admission Date: [**2136-8-23**] Discharge Date: [**2136-8-28**]
Date of Birth: [**2077-1-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest discomfort
Major Surgical or Invasive Procedure:
[**2136-8-23**] Cardiac Catheterization
[**2136-8-23**] Four Vessel Coronary Artery Bypass Grafting utilizing
left internal mammary artery to left anterior descending, vein
grafts to ramus and right coronary artery
History of Present Illness:
This is a 59 year old male with strong family history of
coronary artery disease. He recently [**Month/Day/Year 1834**] stressing testing
due to complaints of exertional chest discomfort. The stress
test was positive for ischemia, and he was subsequently admitted
to the [**Hospital1 18**] for cardiac catheterization.
Past Medical History:
Hypertension
Hyperlipidemia
GERD
Benign Prostatic Hypertrophy
Prior Neck Surgery
Social History:
Quit tobacco over 15 years ago. Admits to only rare ETOH.
Employed as an engineer. He is married.
Family History:
Father died of an MI at age 60.
Physical Exam:
Vitals: BP 180/82, HR 65, RR 19
General: WDWN male in no acute distress, bed rest [**2-10**] cath
HEENT: Oropharynx benign, EOMI
Neck: Supple, no JVD
Lungs: CTA bilaterally
Heart: Regular rate and rhythm, normal s1s2, no murmur or rub
Abdomen: Soft, nontender with normoactive bowel sounds
Ext: Warm, no edema
Pulses: 2+ distally
Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal
deficits noted
Pertinent Results:
[**2136-8-23**] Cath: Coronary angiography in this right dominant system
demonstrated one vessel disease. The LMCA had a 80% distal
stenosis. The LAD had moderate diffuse disease. The left
circumflex artery had mild luminal irregularities. The RCA had
60% stenosis in the mid section.
[**2136-8-23**] Echo: PRE-BYPASS: 1. The left atrium is moderately
dilated. No mass/thrombus is seen in the left atrium or left
atrial appendage. No thrombus is seen in the left atrial
appendage. 2. No atrial septal defect is seen by 2D or color
Doppler. 3. Overall left ventricular systolic function is low
normal (LVEF 50-55%). 4. The right ventricular cavity is mildly
dilated. 5. There are simple atheroma in the descending thoracic
aorta. 6. There are three aortic valve leaflets. The aortic
valve leaflets are mildly thickened. Trace aortic regurgitation
is seen. 7. The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. 8. The pulmonic valve leaflets
are thickened. 9. There is no pericardial effusion. Post-bypass:
On infusion of phenylephrine. Improved biventricular systolic
function. LVEF now 60%. Mild MR. [**First Name (Titles) **] [**Last Name (Titles) **], TR, PI. Aortic
contour is normal postdecannulation.
[**2136-8-26**] CXR: Widening of left cardiomediastinal contour is
stable in appearance compared to previous postoperative
radiographs. Right internal jugular vascular catheter has been
removed with no evidence of pneumothorax. Unusual lucency is
identified within the left retrocardiac region on only the PA
view without comparable finding on lateral view. Left lower lobe
atelectasis shows interval improvement. Small pleural effusions
are present bilaterally. Within the imaged portion of the upper
abdomen, mildly distended loops of bowel are present, possibly
due to postoperative ileus but incompletely evaluated on this
study.
[**2136-8-23**] 09:40AM BLOOD WBC-7.0 RBC-4.58* Hgb-15.1 Hct-42.1
MCV-92 MCH-32.9* MCHC-35.7* RDW-13.3 Plt Ct-215
[**2136-8-25**] 02:55AM BLOOD WBC-13.4* RBC-2.58*# Hgb-8.4*# Hct-23.9*#
MCV-93 MCH-32.7* MCHC-35.3* RDW-13.6 Plt Ct-138*
[**2136-8-27**] 06:20AM BLOOD WBC-7.1 RBC-3.31* Hgb-10.4* Hct-30.0*
MCV-91 MCH-31.4 MCHC-34.6 RDW-14.1 Plt Ct-146*
[**2136-8-23**] 09:40AM BLOOD PT-12.4 INR(PT)-1.1
[**2136-8-25**] 02:55AM BLOOD PT-14.7* PTT-28.4 INR(PT)-1.3*
[**2136-8-23**] 09:40AM BLOOD Glucose-110* UreaN-17 Creat-1.2 Na-141
K-4.9 Cl-105 HCO3-27 AnGap-14
[**2136-8-27**] 06:20AM BLOOD Glucose-105 UreaN-18 Creat-1.2 Na-139
K-4.1 Cl-103 HCO3-28 AnGap-12
[**2136-8-27**] 06:20AM BLOOD Calcium-8.1* Phos-2.2* Mg-2.2
Brief Hospital Course:
Mr. [**Known lastname 36546**] [**Last Name (Titles) 1834**] cardiac catheterization which revealed
a severe 80% left main lesion. Given his critical coronary
anatomy, he was urgently taken to the operating room where
coronary artery bypass grafting was performed by Dr. [**Last Name (STitle) **].
For surgical details, please see separate dictated operative
note. Following the operation, he was brought to the CSRU for
invasive monitoring. Within 24 hours, he awoke neurologically
intact and was extubated. He maintained stable hemodynamics and
weaned from intravenous therapy without difficulty. His CSRU
course was otherwise uneventful and he transferred to the SDU on
postoperative day one. He tolerated beta blockade and remained
in a normal sinus rhythm. He was given several units of packed
red blood cells for a postoperative anemia. Over several days,
beta blockade was advanced as tolerated and he continued to make
clinical improvements with diuresis. He was eventually cleared
for discharge to home on postoperative day five with VNA
services and the appropriate follow-up appointments.
Medications on Admission:
Lisinopril 10 [**Hospital1 **], Zocor 40 qd, Aciphex 40 qd, Doxasozin 1 qd
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*0*
7. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
10 days.
Disp:*10 Tablet(s)* Refills:*0*
9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 10 days.
Disp:*20 Capsule, Sustained Release(s)* Refills:*0*
10. preop meds
Please do not take your lisinopril until instructed by your
cardiologist
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery Disease - s/p Coronary Artery Bypass Graft
Postoperative Anemia
PMH: Hypertension, Hyperlipidemia, Gastroesophageal Reflux
Disease, Benign Prostatic Hypertrophy
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule all appointments
Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] in [**2-11**] weeks
Dr. [**Last Name (STitle) 2472**] in 1 weeks [**Telephone/Fax (1) 133**]
Please schedule wound check with RN [**Telephone/Fax (1) 3633**]
Completed by:[**2136-8-28**]
|
[
"41401",
"2859",
"4019",
"2724",
"53081"
] |
Admission Date: [**2188-10-27**] Discharge Date: [**2189-1-11**]
Service:
HISTORY OF THE PRESENT ILLNESS: This is one of several [**Hospital3 **] Hospital admissions for this elderly male.
The history of this admission goes back to a previous
admission in [**2188-9-14**] when the patient was admitted
for repair of an incarcerated paraileostomal hernia in the
setting of a prior hernia repair. This operation itself
followed a panproctocolectomy for Crohn's disease.
Following that operation, the patient appeared to be doing
well and was, however, readmitted to the hospital on [**2188-10-13**]
until [**2188-10-21**] with what appeared to be left upper quadrant
pain and a hematoma but there was nothing that appeared to
warrant surgery. He was consequently discharged home on
[**2188-10-21**] but then readmitted on [**2188-10-27**] which is the date of
this admission.
The reason for this readmission was that the patient
continued to have developed temperatures and a high white
cell count while an outpatient and developed increasing left
upper quadrant pain. On this occasion, he was readmitted and
CAT scanned and a fluid collection which was not evident on
the previous admission was drained. He was then admitted to
the floor for further follow-up.
PRIOR MEDICAL HISTORY: Status post panproctocolectomy for
Crohn's disease.
PHYSICAL EXAMINATION: General: The physical examination
revealed an elderly male. HEENT: Normal. Heart and lungs:
Clear. Abdomen: Well-healed midline incision, an ostomy on
the left lower quadrant and a drain site in the right upper
quadrant.
HOSPITAL COURSE: The patient's condition appears to have
evolved following his admission in that he developed a
clear-cut enterocutaneous fistula which began to necessitate
via the midline incision. Much thought was given to how to
deal with this including consultations with other surgeons.
He was, therefore, placed on intravenous elementation in the
hopes that this fistula would either be controlled on its own
or that his metabolic state would allow us to reenter his
abdomen and try to address the situation.
On [**2188-12-6**], he was taken back to the Operating Room in hopes
of being able to create an ileostomy proximal to the fistula.
However, this operation proved to be impossible owing to
dense adhesions within the abdomen. Nothing further was done
and he was, therefore, returned to the floor for further
intravenous elementation, antibiotics, and all supportive
care. Despite this, however, the patient continued to
dwindle and he finally died on [**2189-1-11**].
FINAL DIAGNOSIS: Enterocutaneous fistula.
OPERATION PERFORMED: Exploratory laparotomy.
DISPOSITION: The patient died.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11126**]
Dictated By:[**Last Name (NamePattern4) 22919**]
MEDQUIST36
D: [**2189-5-17**] 04:17
T: [**2189-5-21**] 20:04
JOB#: [**Job Number 29622**]
|
[
"4280",
"51881",
"5849",
"2762"
] |
Admission Date: [**2169-12-12**] Discharge Date: [**2169-12-15**]
Date of Birth: [**2108-11-14**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 52818**] is a 61 year old
male with a history of hypertension and arthritis who was
admitted on [**2169-12-12**] after he presented with a sudden onset of
[**9-2**] anterior chest pain and back pain while shopping. He
reported the pain radiated from his chest to his abdomen. He
denied any visual changes, lightheadedness, headache,
shortness of breath, nausea or vomiting. He said the pain
did not resolve at home, and he subsequently went to an
outside hospital. At the outside hospital, his blood
pressure was noted to be 206/104 with a repeat of 150/68 and
a heart rate in the 70's. A chest x-ray at the outside
hospital revealed a widened mediastinum. CT scan showed a
type B aortic dissection without extravasating contrast, with
the dissection being from the level of the left subclavian to
the level of the superior mesenteric artery. The renal
arteries were spared. There was evidence of old thrombus in
the lumen. Electrocardiogram at the outside hospital showed
left ventricular hypertrophy, questionable lateral T-wave
inversions, and an old inferior infarct. He was given 5 mg
of intravenous Lopressor times two, aspirin, Nitroglycerin,
and started on a Nipride drip. Cardiac enzymes times one
were negative at the outside hospital.
He was transferred to [**Hospital1 69**]
due to the lack of beds at the outside hospital. In the
Emergency Room at [**Hospital1 69**], he
was maintained on a Nipride drip. Blood pressure in his
right arm revealed a systolic pressure of 130, with a
systolic pressure of 140 in his left arm. He was transferred
to the Cardiac Care Unit for blood pressure control and
monitoring.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Arthritis.
3. Status post hernia repair.
4. Status post tonsillectomy.
5. History of motor vehicle accident three years ago.
SOCIAL HISTORY: Mr. [**Known lastname 52818**] has smoked one pack of
cigarettes per day for approximately 20 years. He is married
with three children.
FAMILY HISTORY: He denies any family history of aneurysms or
coronary artery disease.
HOME MEDICATIONS: He reports that he takes a blood pressure
pill at home, however, he does not know the name of it.
IMAGING STUDIES ON ADMISSION: CT scan at [**Hospital1 346**] revealed a thoracoabdominal
aneurysm, a type B aortic dissection extending from the level
of the left subclavian to the level of the superior
mesenteric artery. It tapered off to normal caliber at the
level of the renal arteries.
HOSPITAL COURSE: Mr. [**Known lastname 52818**] was admitted to the Cardiac
Care Unit Service for blood pressure control and monitoring.
He was initially started on a Nipride drip and beta-blocker.
His goal blood pressure was 100-120 systolic and heart rate
less than 70. There was difficulty controlling his heart
rate despite escalating doses of Metoprolol. He was also
tried on Diltiazem with little change in heart rate. He was
eventually able to be weaned off the Nipride drip as he was
started on escalating doses of Captopril. Once he was on a
stable dose of Metoprolol and Captopril, he was transferred
to the floor still followed by the Cardiac Care Unit Service.
All of this happened on [**2169-12-15**].
Prior to this transfer, on [**2169-12-14**], he had grown gram
negative rods out of his blood. He had been spiking
temperatures, but yet had no localizing symptoms of
infection. Chest x-ray revealed no presence of infiltrate,
and an abdominal CT was obtained on [**2169-12-15**] to look for any
signs of abdominal abscess or infection. After being brought
to the General Medical Floor, after abdominal CT, he was
subsequently found on the floor by the nurse and a code was
called. He had PEA arrested, and he was coded by the medical
team for approximately 30 minutes with an inability to
resuscitate him. Despite all efforts for resuscitation, Mr.
[**Known lastname 52818**] passed away on [**2169-12-15**]. The attending, Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**], was present.
The family was contact[**Name (NI) **] and an autopsy will be performed.
[**First Name4 (NamePattern1) 610**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 19954**]
Dictated By:[**Last Name (NamePattern1) 9820**]
MEDQUIST36
D: [**2169-12-17**] 13:03
T: [**2169-12-17**] 14:34
JOB#: [**Job Number 52819**]
|
[
"4019",
"412",
"3051"
] |
Admission Date: [**2113-2-10**] Discharge Date: [**2113-2-15**]
Date of Birth: [**2036-9-8**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This patient came into the
hospital originally on [**2113-2-3**] and was referred to
cardiac surgery after cardiac catheterization revealed three-
vessel disease. This 76-year-old gentleman presented to an
outside hospital with vertigo. The head CT was negative. He
had an exercise tolerance test on [**5-6**] that showed
anterior akinesis with exercise and was referred into [**Hospital1 **] for cardiac catheterization.
PAST MEDICAL HISTORY: Hernia repair x 3.
Nephrolithiasis.
Osteoarthritis of the neck and lumbar region.
Hypercholesterolemia.
ORIF of the right ankle.
Pilonidal cyst removal.
MEDS AT HOME:
1. Aspirin on Monday, Wednesday and Friday.
2. Multivitamin.
At [**Hospital1 **], the following medications were
added:
1. Metoprolol 12.5 mg po bid.
2. Aspirin 325 mg po qd.
3. Colace 100 mg po bid.
ALLERGIES: He had no known drug allergies.
SOCIAL HISTORY: He had a remote tobacco history since he
quit 30 years ago. He is married and lives with his wife.
[**Name (NI) **] use of alcohol, or recreational drugs noted by the
patient.
FAMILY HISTORY: Positive family history, as his brother had
undergone CABG surgery also.
REVIEW OF SYMPTOMS: He had no chest pain, palpitations,
edema, orthopnea. No gastritis, peptic ulcer disease. No
problems with nausea, vomiting, diarrhea, or constipation.
He had no melena or hematochezia reported. No history of
peripheral vascular disease, claudication, diabetes,
hypertension. No symptoms of CVA or TIA.
LABS PREOPERATIVE ON [**2-3**]: White count 8.6, hematocrit
41.8, platelet count 158,000, PT 13.9, PTT 53.4, INR 1.3,
sodium 140, K 3.8, chloride 103, CO2 26, BUN 20, creatinine
0.8 with a blood sugar of 95, ALT 21, AST 19, alk phos 51,
total bili 0.5, albumin 3.8. His EKG showed first degree AV
block at 72 beats per minute with a right bundle branch
block, and Q waves present in III and F, as well as flipped T
waves in AVL and V2. Cardiac catheterization showed the left
main arose from the noncoronary cusp. The LAD had serial 90
percent lesions, OM1 70-80 percent lesion, OM2 70-80 percent
lesion, RCA proximally 50 percent lesion and distal 80
percent lesion, and a left posterolateral 80 percent lesion
with an ejection fraction of 50 percent.
EXAM: The patient was afebrile with a heart rate of 67, in
sinus rhythm, with a blood pressure of 147/86, respirations
20, satting 96 percent on room air. He was alert and
oriented x 3. NAD. Nonfocal exam. His pupils were equal
and reactive to light and accommodation. EOMS were normal.
He was anicteric. He had a normal oropharynx. His neck was
supple with no lymphadenopathy or thyromegaly. No JVD. No
bruits heard. Lungs were clear bilaterally. Heart was
regular rate and rhythm with S1 and S2 sounds present, but no
murmur, rub, or gallop. His abdomen was soft, nontender,
nondistended with normal bowel sounds. No hepatosplenomegaly
or masses palpated. Extremities were warm and well-perfused
with no clubbing, cyanosis, edema, or varicosities. His
pulses were as follows: 2 plus bilaterally on the carotids
with no bruits, 2 plus bilaterally on femorals, 2 plus
bilaterally on radials, and 2 plus bilaterally on both DP and
PT peripheral pulses.
ASSESSMENT: The patient did have severe two-vessel disease
with an anomalous left main. He was referred to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) 2545**] for cardiac surgery with the plan as patient to go
home as asymptomatic and stable and return for surgery.
HO[**Last Name (STitle) **] COURSE: The patient was readmitted on [**2113-2-10**] to Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] service, and he underwent a
coronary artery bypass grafting x 3 with LIMA to the LAD,
vein graft to the posterolateral, and a vein graft to the OM.
In addition, an endarterectomy of the proximal LAD was
performed with a vein patch angioplasty proximal to the LIMA-
LAD anastomosis. The patient was transferred to
Cardiothoracic ICU in stable condition on Neo-Synephrine drip
and a propofol drip.
On postoperative day 1, the patient was doing well
postoperatively and was extubated at 2230 in the evening with
good ABGs, and continued to be monitored closely, but was
proceeding well. The Neo-Synephrine was weaned on
postoperative day 2. The patient had no events overnight.
He had a T-max of 100.3. He was sinus tachycardia at 108
with a blood pressure of 118/52, and was satting 96 percent
on 1 liter nasal cannula. He remained on Neo-Synephrine drip
at 1 mcg/kg/min. The patient started aspirin and Plavix
both. He remained in the Cardiothoracic ICU. Postoperative
labs as follows: K 3.9, BUN 20, creatinine 0.8. Hematocrit
dropped slightly from 26.5 to 21.5. The patient was
transfused 2 units of packed red blood cells. Chest x-ray
was repeated, and Lasix diuresis was begun. The patient
remained in the ICU to manage his dependence on Neo-
Synephrine and his dropping hematocrit.
On postoperative day 3, his chest tubes had been pulled. He
did receive the 2 units of packed red blood cells on the day
prior. He was restarted on his beta blocker, metoprolol 12.5
[**Hospital1 **], in addition to the aspirin and Plavix. He was in sinus
rhythm at 90, with a blood pressure of 153/66, with a
reasonable blood gas and was satting 94 percent on 1 liter
nasal cannula. Hematocrit remained increased to 25.5 post-
transfusion, with a BUN of 17, creatinine 0.6. Lasix was
increased to 20 [**Hospital1 **]. Pacing wires were discontinued. The
patient was transferred out to the floor where he began his
ambulation with physical therapy and the nursing staff, and
to continue working with them.
He did have an episode of increased heart rate to 110.
Lopressor was given on the 22 at 1800 in the evening. This
dropped his heart rate down into the 80's again. He did have
a complaint of some tooth pain on the right side and had a
little bit of serosanguineous drainage from the distal
portion of his sternal incision. He continued ambulating
tid. Discharge teaching and planning was begun. The serous
drainage from his chest was managed, and he continued with
pulmonary toilet and ambulation.
On postoperative day 4, the patient still was complaining of
some tooth pain. He continued his ambulation on the floor.
He had a heart rate of 88 with a blood pressure of 90/56, and
remained in stable condition. BUN 17, creatinine 0.6 from
the day prior. His lungs were clear bilaterally. His
abdominal exam was benign. His wounds were clean, dry and
intact. His heart was regular rate and rhythm. The plan was
to try and DC him home if possible after evaluation by
physical therapy. The patient had some issue with
constipation for which Milk of Magnesia was prescribed.
Labs on the 23 were as follows: White count 7.5, hematocrit
28.4, BUN 17, creatinine 0.8, blood sugar 123. Magnesium was
supplemented when the lab value returned at 1.8 and was
repleted. K was 3.7, sodium 140. His heart rate increased
slightly during the day from sinus rhythm to sinus tach with
his known bundle branch block. He was seen by case
management on the 23. PT evaluated the patient and
anticipated that he would be able to go home as soon as he
was medically stable. The plan was to follow-up with Care
Group Home Care and possibly [**Last Name (un) **] for better sugar
management.
On postoperative day 5, the patient was stable
hemodynamically with a blood pressure of 140/67, in sinus
rhythm in the 80's, satting 96 percent on room air. He did
finally have the bowel movement. He was receiving Ambien
also to help a little bit with sleep. His heart was regular
rate and rhythm. He was in no apparent distress. The [**Last Name (un) **]
consult was obtained. His lungs were clear. His abdomen was
benign. It was recommended to the patient that he have
antibiotics pre any dental procedures. [**Last Name (un) **] consult was
done. Please refer to their note on the 24. The patient was
given information about scheduling an appointment as an
outpatient for follow-up, as well as educational training for
better management of his diabetes.
On the 24, the patient was discharged to home. His exam was
benign. His labs were as follows: Sodium 140, K 3.7,
chloride 101, CO2 32, BUN 17, creatinine 0.8, white count 7.5
and 28.4. All these labs were previously noted from the day
before.
DISCHARGE MEDICATIONS:
1. Metoprolol 25 mg po bid.
2. Lasix 20 mg po bid x 7 days.
3. KCL 20 mEq po bid x 7 days.
4. Colace 100 mg po bid.
5. Aspirin 325 mg po qd.
6. Percocet 1-2 tabs po prn pain q 4-6 h.
7. Plavix 75 mg po qd.
8. Ambien 5 mg po hs prn.
FO[**Last Name (STitle) 996**]P: The patient was advised to come back to the [**Hospital 409**]
Clinic on FAR-2 in 1 week for wound check. Follow-up with
his PCP and cardiologist in approximately 1-2 weeks. Make
his appointment with the [**Hospital **] Clinic as he had been
directed to. See Dr. [**Last Name (Prefixes) **] for his postoperative visit
in the office at 4 weeks.
DISCHARGE DIAGNOSES: Status post coronary artery bypass
grafting x 3.
Coronary artery disease.
Nephrolithiasis.
Osteoarthritis.
Hypercholesterolemia.
Status post hernia repair x 3.
Status post open reduction and internal fixation, right
ankle.
Status post pilonidal cyst removal.
DISCHARGE STATUS: Discharged to home, with follow-up
instructions aforementioned, on [**2113-2-15**].
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2113-5-10**] 11:23:48
T: [**2113-5-10**] 13:30:20
Job#: [**Job Number 2547**]
|
[
"41401",
"2720"
] |
Admission Date: [**2165-12-2**] Discharge Date: [**2165-12-6**]
Date of Birth: [**2165-12-2**] Sex: M
Service: NEONATOLOGY ATTENDING
HISTORY OF PRESENT ILLNESS: Baby [**Name (NI) **] [**Known lastname 60174**], [**Name2 (NI) 37336**] II, was
a 1,635 gm product of a 33-3/7 weeks spontaneous dichorionic-
triamniotic [**Name2 (NI) 37336**] gestation, EDC [**2166-1-17**], born to a 27-
year-old G5, P0 mom, with [**Name2 (NI) **] type AB positive, antibody
negative, RPR nonreactive, rubella immune, Hep-B negative,
and GBS unknown.
Mom's history is significant for a spontaneous abortion at 15
weeks with cerclage placement in [**2163**], a 23-week IUFD
secondary to PROM at 22 weeks at Women's and Infant's
Hospital in [**Doctor Last Name **]. Mom also has a maternal history of
hypothyroidism, for which she receives Levoxyl.
This pregnancy was complicated by preterm labor at 26 weeks.
Mom was admitted to the [**Hospital6 256**]
and treated with betamethasone and magnesium sulfate, at
which time the preterm resolved, but she was kept in house
for close monitoring. Her pelvic bones separated, and mom
was maintained in traction. The C-section was scheduled
because of maternal indications.
There was no fever prior to delivery. Rupture of membranes
occurred at delivery. There was no increased fetal heart
rate. Mom was not treated with antibiotics prior to
delivery.
The infant was born in a breech position with nuchal cord x
1. He required blow-by oxygen in the delivery room x several
minutes. His Apgar scores were 7 and 9 at 1 and 5 minutes.
He was taken to the NICU for further management.
PHYSICAL EXAM ON ADMISSION: Birthweight of 1,635 gm, length
of 43 cm, head circumference of 30 cm. Vital signs: T 97.8,
P 134 R40-50, BP 79/66.
GENERAL: Preterm male in radiant warmer, in no apparent
distress.
HEENT: AFOF, OP clear, palate intact, red reflex present
bilaterally, neck supple, no crepitus.
RESPIRATORY: Lungs clear to auscultation bilaterally, good
air entry, no retractions. CARDIAC: RRR, S1, S2 normal, no
murmurs appreciated on exam.
ABDOMEN: Soft, ND, NABS, no masses, no HSM.
EXTREMITIES: No cyanosis or edema, well-perfused, femoral
pulses 2 plus and brisk bilaterally. No ortolani/barlow sign
GU: Normal male preterm genitalia descended bilaterally.
Left testis slightly larger than right testis with a mild
hydrocele.
NEUROLOGIC: Appropriate tone and exam. Spontaneous movement
of all four extremities. Moro: Sucked. Palmar, plantar,
grasp reflex intact.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
1. RESPIRATORY: The patient received blow-by oxygen for
several minutes in the delivery room, after which he did
not require any supplemental oxygen or further invasive
measures. The patient remained stable on room air for the
remainder of his hospital course. The patient did not
exhibit any signs of apnea.
2. CARDIOVASCULAR: The patient was cardiovascularly stable
throughout his hospital course.
3. FLUIDS, ELECTROLYTES AND NUTRITION: This patient was
placed on IV fluids of D10W at 80 cc/kg/D and NPO for the
first 24 hours. On day of life number 2, the patient was
started on PO feeds of breast milk or Special Care 20
kcal/oz with supplemental IV fluid. By day of life number
3, the patient had been advanced to full feeds of total
fluids of 140 cc/kg/D of breast milk or Special Care 20
kcal/oz, partial PO feeds, partial gavage feeds.
4. GI: The patient's bilirubin at birth was 2.8. Bilirubin on
[**2165-12-5**] was 10.3 and phototherapy was started. She is
currently on phototherapy at time of transfer
5. ID: No CBC, or [**Date Range **] cultures, or antibiotics were
obtained on this patient due to the absence of maternal
risk factors for infection.
6. NEUROLOGY: The patient was neurology stable with a normal
neurologic exam throughout his hospital course.
7. SENSORY: The patient has not received a hearing screen prior
to discharge.
8. OPHTHALMOLOGY: The patient did not qualify for an
ophthalmologic exam prior to discharge.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Transfer to [**Hospital **] Hospital in [**Location (un) 50909**],
[**Doctor Last Name **].
NAME OF PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
CARE RECOMMENDATION AT TRANSFER:
1. Feeds at discharge are breast milk or Special Care 20
kcal/oz, total fluids of 140 cc/kg/D PO/PG.
2. Medications: None.
3. Car seat positioning screening will not be done prior to
transfer.
4. State newborn screening test sent on day of life 3.
5. No immunizations administered during this hospitalization.
DISCHARGE DIAGNOSES:
1. Prematurity at 33-3/7 weeks gestational age.
2. Immature feeding.
3. Respiratory distress/resolved.
4. Hyperbilirubinemia
Reviewed By: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 53043**], [**MD Number(1) 53044**]
Dictated By:[**Name8 (MD) **]
MEDQUIST36
D: [**2165-12-5**] 10:15:04
T: [**2165-12-5**] 11:00:28
Job#: [**Job Number 60176**]
|
[
"7742"
] |
Admission Date: [**2201-7-15**] Discharge Date: [**2201-7-30**]
Date of Birth: [**2178-10-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
abdominal pain and UTI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In [**Month (only) 958**] the patient underwent sigmoid colectomy w/end colostomy
for malrotation & megacolon limited to the rectosigmoid in a
combined procedure with OB/Gyn performing a TAH/RSO for pelvic
abscess. She recovered from that operation and was doing well
until she presented last month with a small bowel obstruction
neccesitating extensive adhesiolysis, enterectomy and completion
subtotal colectomy with an end ileostomy on [**2201-6-11**] with Dr.
[**Last Name (STitle) 468**]. She recovered and was seen in clinic Monday appearing
healthy, vibrant and eating well. This morning ~8am she was
noted to be much more "fussy" according to her mother and
appeared to be distressed about some lower abdominal pain.
Although she was tolerating oral intake, it was felt to be
somewhat diminished. She was not experiencing any fevers,
nausea or vomiting, however. Of note, her ostomy output was not
significantly diminished (albeit somewhat thin) and had copious
gas in her appliance.
Past Medical History:
Trisomy 13 Mosaicism
Mentral Retardation - nonverbal at BL
Cardiomyopathy - Unknown status. Had ECHO last at NEM (pending).
PDA (congenital, closed per mother without OR)
"Slow heartbeat"
Aspiration PNA
Neck anatomic deformity with inverted crichoid/hypoid. Pt
assists herself with her fingers on the outside of her throat to
pass food.
GYN HISTORY: LMP: [**2201-4-11**], regular menses with cramping
OB HISTORY:G:0
PAST SURGICAL HISTORY: Fundoplication
end colostomy (hartmans pouch), R salpingoophrectomy, TAH,
removal of pelvic mass [**2201-4-17**]
Social History:
SOCIAL HISTORY: No T/ETOH/IV drugs
Family History:
Breast cancer
Physical Exam:
PE: 98.9 114 119/84 18 93%/RA
Gen: NAD, A&Ox3, MM dry, (-)scleral icterus
Pul: CTAB
Cor: tachy, regular
Abd: soft/ND (+)mild suprapubic tenderness (-)guarding(-)tympani
stoma viable (-)stricture or prolapse on digital exam
Pertinent Results:
36.2 12 138 101 12 Lactate 1.2
11.2 >---- --< 1.0 ---|---|--< 111 UA(+)LE/NO3; WBC>50
221 27 4.6 28 0.4
AXR: mildly dilated small bowel with scant air-fluid levels
[**7-16**] CXR Limited, but no acute cardiopulmonary process.
Brief Hospital Course:
1) Recurrent Aspiration complicated by Aspiration PNA:
The patient required 3L O2 via NC in the AM of HD2 and was
slowly weaned off to RA. Then around noon of HD 2 on [**7-17**], she
developed hypoxemia to the 70's and was triggered. ECG showed
sinus tachycardia, CXR showed some fluid, and ABG showed
hypoxemia. The patient was placed on 100% NRB and given 20IV
lasix. The patient responded well and started to saturate in
the low 90's on NRB. The patient was then given digoxin IV and
another dose of lasix with minimal response. She continued to
decompensate and was transferred to the SICU. She was intubated
for hypoxic respiratory failure and started on Vanco/Zosyn IV.
A bronchoscopy and BAL was performed while she was intubated
which showed growth of oropharnygeal flora as well as a right
lower lobe opacification and mucous plugging of the right main
stem
bronchus suggesting post-obstructive pneumonia. Given no growth
of MRSA or hx of such, she was mainatined on a 10day course of
IV Zosyn for this aspiration PNA which was completed during her
hospitalization. She continued to require supplemental oxygen
following this slowly resolving aspiration event and was
discharged home with home o2.
2) Abdominal Pain
Initially admitted to the surgical service with abdominal pain
and concern for a partial SBO on imaging. She continued to have
good ostomy output and she was managed conservatively. Her
abdominal pain resolved and at discharge she continued to have
good ostomy output.
3) UTI:
On admission to the surgical service, had dirty U/A that was
treated with 3 days of PO cipro (no culture sent). Her sx's
resolved and subsequent U/As were negative.
4) FEN/aspiration risk:
Pt known to have constant aspiration risk. She is well known to
the S&S eval team here at [**Hospital1 18**]. A repeat S&S eval showed risk
of aspiration for all consistencies. She was kept NPO and
mainatined on TFs through an NGT during her stay. A discussion
regarding the results of her S&S eval was had with her HCP
mother who emphasized that she is careful about having her sit
upright at all times while eating at home and that she has not
had an episode of aspiration at home and rather felt that her
aspiration events while hospitalized were in the setting of her
acute illness. A family meeting during her hospitalization was
held with attending Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], speech/swallow team, and
case management. A full discussion regarding her risks of
aspiration were discussed as well as the option of having a PEG
placed for enteral nutrition. Her mother [**Name (NI) 382**] did not want PEG
tube placement at this time, but did state that if she developed
aspiration events at home she will consider this in the future.
She was maintained on a pureed diet with thickened liquids under
strict supervision by the RNs along with always sitting straight
upright to prevent aspiration. The speech/swallow team had
multiple teaching sessions with the parents to attempt to
minimize aspiration. She should consider bringing her back for
outpatient video S&S again in 3 months when she is healthy to
assess her swallow function when she is home and healthy.
5) ARF:
Developed acute renal failure while hospitalized, felt due to
temporary hypoxia and ATN while being intubated along with
contrast nephropathy. A workup including urine eos to exclude
AIN and renal U/S to exclude hydronephrosis was performed and
negative. Her Cr trended back down to normal range and on day of
discharge her Cr had normalized.
6) CHF:
Known underlying cardiomyopathy, EF 35%. Takes Lasix at home
but due to her NPO status through much of her stay and
anticipated difficulty maintaining hydration at home, lasix has
been held. Discussed with pt's family, recommend re-evaluation
as an outpt to determine when and if lasix should be restarted.
Discharge letter has been written to her PCP
DISPO - Discharged home on supplemental oxygen to follow up with
her PCP.
Medications on Admission:
enalapril 10', digoxin 0.25', lasix 10', sertraline 50', miralax
Discharge Medications:
1. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Miralax 100 % Powder Sig: One (1) packet PO once a day as
needed for constipation.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Digoxin 50 mcg/mL Solution Sig: Two (2) mL PO once a day.
5. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO once a
day.
6. Home Oxygen
Please provide continous 2-6 liters of oxygen at all times.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
) Severe aspiration pneumonia
2) Hypoxic respiratory failure requiring intubation
3) Recurrent aspiration
4) Possible early or partial small bowel obstruction, resolved
without intervention
5) Urinary tract infection
6) Acute renal failure secondary to contrast nephropathy,
resolved
Secondary:
Trisomy 13 Mosaicism
Mentral Retardation - nonverbal at BL
Cardiomyopathy - Unknown status. TTE [**4-11**] LVEF 30-35%
PDA (congenital, closed per mother without OR)
"Slow heartbeat"
Aspiration PNA
Hx neck anatomic deformity with inverted crichoid/hypoid. Pt
assists herself with her fingers on the outside of her throat
to
pass food.
hx sigmoidectomy with end colostomy for malrotation and
megacolon
s/p TAH/RSO for removal of pelvic mas [**4-11**]
hx SBO s/p enterectomy and subtotal colectomy with end
ileostomy [**6-11**]
Discharge Condition:
Stable for discharge home with oxygen
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to difficulty maintaining
hydration on your restricted diet.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Please resume all regular home medications and take any new meds
as ordered.
Please follow up with your appointments as below.
Followup Instructions:
Please call Dr. [**Last Name (STitle) 28118**] after discharge to schedule a follow up
appointment 7-10 days after discharge - please discuss whether
to resume your Lasix as this is being held when you go home.
PLEASE FOLLOW UP WITH THE BELOW SCHEDULED APPOINTMENTS:
Provider: [**First Name8 (NamePattern2) 251**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 476**] Date/Time:[**2201-11-23**]
10:45
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2201-7-31**]
|
[
"5990",
"5070",
"51881",
"5849",
"0389",
"4280"
] |
Admission Date: [**2154-8-27**] Discharge Date: [**2154-9-6**]
Date of Birth: [**2090-5-30**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Severe left main coronary artery lesion - transferred for
coronary artery bypass grafting
Major Surgical or Invasive Procedure:
[**2154-9-2**] Three vessel coronary artery bypass grafting utlizing
the left internal mammary artery to left anterior descending;
saphenous vein graft to obtuse marginal and saphenous vein graft
to posterior descending artery.
[**2154-8-29**] Stenting of left internal carotid artery
History of Present Illness:
Mrs. [**Known lastname **] is a 64 year old female with multiple cardiac risk
factors. She has a history of a positive stress test. During an
evaluation for her peripheral vascular disease with
claudication, she underwent cardiac catheterization. This was
notable for an 80% ostial left main lesion with a totally
occluded right coronary artery and 70% stenosis of the
circumflex. Ventriculogram revealed an LVEF of 52% without
mitral regurgitation. Her aortic root was normal. Based on the
above results, she was transferred to the [**Hospital1 18**] for surgical
coronary revascularization.
Past Medical History:
Coronary artery disease, Carotid artery stenosis, Hypertension,
Hypercholesterolemia, Diabetes mellitus, Peripheral Vascular
Disease, Hypothyroidism
Social History:
50-100 pack year history of tobacco. She denies excessive ETOH.
She is married and lives with her husband. They have one son.
Denies IVDA.
Family History:
Denies premature coronary disease. Mother died of MI at age 80.
Father died of brain tumor.
Physical Exam:
Temp 98.5, BP 120/48, Pulse 50-60, Resp 18 with 96% room air
saturations.
General: Well developed female in no acute distress
HEENT: Oropharynx benign
Neck: Supple, no JVD, ?soft left bruit noted
Lungs: clear bilaterally
Heart: regular rate and rhythm, normal s1s2, no murmur or rub
Abdomen: benign
Extremities: warm, no edema or cyanosis
Pulses: 1+ distal pulses
Neuro: alert and oriented, cranial nerves grossly intact, good
strength in all extremities, no focal deficits noted
PVRs: Right ABI 0.81(DP) 0.92(PT) / Left ABI 0.62(DP) 0.74(PT)
PVR with exercise: Right ABI 0.47(PT) / Left ABI 0.28(PT)
Pertinent Results:
[**2154-9-6**] 05:45AM BLOOD WBC-9.4 RBC-3.25* Hgb-9.3* Hct-27.2*
MCV-84 MCH-28.6 MCHC-34.2 RDW-14.9 Plt Ct-229
[**2154-9-6**] 05:45AM BLOOD Glucose-99 UreaN-11 Creat-0.9 Na-144
K-4.5 Cl-107 HCO3-29 AnGap-13
[**2154-9-6**] 05:45AM BLOOD Mg-1.7
[**2154-8-28**] Carotid Duplex Ultrasound
1. Moderate stenosis of the right internal carotid artery
between 40 to 59%.
2. Severe stenosis of the left internal carotid artery between
80 and 99%.
[**2154-9-2**] ECHO
The left atrium is mildly dilated. Left ventricular wall
thicknesses and
cavity size are normal. There is mild regional left ventricular
systolic
dysfunction with focal hypokinesis of the basal half of the
inferolateral
wall. The remaining left ventricular segments contract normally.
Right
ventricular chamber size and free wall motion are normal. The
ascending aorta and aortic arch are mildly dilated. The aortic
valve leaflets are mildly thickened. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. There
is no pericardial effusion.
[**2154-9-2**] CXR
Status post median sternotomy and post-CABG. The left chest tube
has been removed. The mediastinal and hilar contours are stable.
There is a left basilar atelectasis and tiny bilateral
effusions. No areas of consolidations are seen. There is no
pneumothorax.
[**2154-9-2**] EKG
Sinus rhythm
Low limb leads QRS voltage - is nonspecific
Consider left anterior fascicular block
Late precordial QRS transition - is nonspecific
Since previous tracing of [**2154-8-25**], borderline left axis
deviation present and ST-T wave changes decreased
Brief Hospital Course:
Mrs. [**Known lastname **] was admitted and underwent further preoperative
evaluation. She remained pain free on medical therapy. A carotid
ultrasound on [**8-28**] was notable for moderate stenosis of the
right internal carotid artery(between 40 to 59%) and severe
stenosis of the left internal carotid artery(between 80 and
99%). The vascular and neurology services were subsequently
consulted. Given her perioperative risk of stroke and that she
was not a carotid endarterectomy candidate at the time, it was
decided to proceed with endovascular revascularization prior to
coronary bypass grfating. On [**8-29**], successful stenting of
the left internal carotid artery was performed. Plavix therapy
was therefore initiated. There were no complications and she
remained neurologically intact. The rest of her preoperative
course was unremarkable.
On[**9-2**], Dr. [**Last Name (STitle) 1290**] performed three vessel coronary
artery bypass grafting utilizing the left internal mammary
artery to left anterior descending artery with
saphenous vein grafts to obtuse marginal and posterior
descending artery. Her operative course was uneventful and she
was brought to the CSRU for further invasive monitoring. Within
24 hours, she awoke neurologically intact and was extubated
without incident. She weaned from intravenous therapy without
complication. She maintained stable hemodynamics and transferred
to the SDU on postoperative day one. Low dose beta blockade was
resumed. She remained in a normal sinus rhythm. All chest tubes
and pacing wires were removed without complication. She was
diuresed toward her preoperative weight as her oral diabetic
agents were resumed. Over several days, she made clinical
improvements and made steady progress with physical therapy. By
discharge, her oxygen saturations on room air were 98%. She was
medically cleared for discharge on postoperative day four. She
will need to remain on Aspirin and Plavix for at least nine
months. Mrs. [**Known lastname **] will follow-up with Dr. [**Last Name (Prefixes) **], her
cardiologist and her primary care physician as an outpatient.
Medications on Admission:
Lipitor 20 qd, Aspirin 325 qd, Effexor 37.5 [**Hospital1 **], Metformin 1000
[**Hospital1 **], Actos 10 qd, HCTZ 12.5 qd, Lisinopril 40 qd, Synthroid 150
mcg qd, Glyburide 2.5 qd
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Venlafaxine 75 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Levothyroxine Sodium 150 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Pioglitazone 15 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 5
days.
Disp:*5 Tablet(s)* Refills:*0*
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5
days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Coronary artery disease - status post coronary artery bypass
grafting, Carotid artery stenosis - status post stenting of left
internal carotid artery, Hypertension, Hypercholesterolemia,
Diabetes mellitus, Peripheral Vascular Disease, Hypothyroidism
Discharge Condition:
Good, stable.
Discharge Instructions:
1)Patient may shower. No creams, lotions or ointments to
incisions.
2)No driving for at least one month
3)No lifting more than 10lbs for at least 10-12 weeks.
Followup Instructions:
Dr. [**Last Name (STitle) 1290**] in 4 weeks
Local PCP and cardiologist in 2 weeks - call for appt
Completed by:[**2154-10-1**]
|
[
"41401",
"25000",
"4019",
"2720",
"2449",
"V1582"
] |
Admission Date: [**2121-6-12**] Discharge Date: [**2121-7-9**]
Date of Birth: [**2066-12-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ciprofloxacin
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Elevated Creatinine on Labs
Major Surgical or Invasive Procedure:
IR guided paracentesis
History of Present Illness:
This is a 54 yo woman with HTN, DM and HCV cirrhosis admitted
for HRS, on liver and renal [**First Name3 (LF) **] list who is being
transfered to MICU for development of AMS and identification of
embolic strokes on head MRI. The history was obtained from chart
and previous providers. Neurology, [**First Name3 (LF) **] and renal are
following.
She was admitted three weeks ago whith worsening abdominal
ascites and found to have hepatorenal syndrome. She had a
dialysis line placed at the begining of [**Month (only) **] and initiated
dialysis. She She also underwent two paracentesis on [**6-14**] (21
WBCs, 94 RBCs, 15 polys, 36 lymphs; culture negative) and [**6-27**] (
4lts therapeutic only). She has been on cipro ppx but changed to
cefpodoxime for long qt recently. Two days ago she was noted to
be unsteady and complained of dizziness, suffered a reporeted
mechanical fall and underwent an inital head CT which was
negative. Subsequently she was noted to have slurred speach,
right eye droop and AMS and Neurology was consulted. Repeat head
CT was negative, but a subsequent MRI was notable for new
embolic appearing stroke. Also of note this morning, after
having been NPO overnight, she was noted to have a blood
pressure in the 80s, but this corrected to her baseline of 90s
with 1 LT NS and albumin. In addition she was also noted to have
asterixis and was started on lactulose. She has been afebrile
and her white count has been wnl.
She has a history of varices on EGD [**3-28**] but no history of bleed.
Currently on nedolol. She has not had encephalopathy before, on
report.
.
Vitals prior to transfer were 97 90/46 63 20 100RA.
.
Review of sytems:
(+) Per HPI
(-) Pt c not communicate.
Past Medical History:
HCV cirrhosis (contracted while working as lab tech),
complicated by portal HTN and ascites, on [**Month/Day (4) **] list,
frequent paracentesis, no history of SBP
DM
CKD Cr 1.7 to 2
HTN
2+ MR
[**First Name (Titles) 105777**] [**Last Name (Titles) 32050**] hernia repair [**5-11**] by Dr. [**Last Name (STitle) **]
Social History:
Works as staff accountant at Sound life financial. Lives in
[**Hospital1 **] with husband. [**Name (NI) **] children. Nonsmoker. No etoh. No ivdu
Family History:
No history of liver disease. Father with CVA in 50s. Mother with
DM and CHF Sister with DM.
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CARDIAC: RRR, normal S1/S2, [**12-27**] blowing systolic murmur
appreciated best at apex, no carotid bruits appreciated,
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2121-6-11**] 09:00AM BLOOD WBC-4.1 RBC-2.31* Hgb-7.2* Hct-22.9*
MCV-99* MCH-31.2 MCHC-31.5 RDW-18.8* Plt Ct-59*
[**2121-6-12**] 07:45PM BLOOD WBC-4.6 RBC-2.41* Hgb-7.4* Hct-24.1*
MCV-100* MCH-30.8 MCHC-30.8* RDW-18.8* Plt Ct-70*
[**2121-7-8**] 05:00AM BLOOD WBC-7.9 RBC-2.49* Hgb-7.9* Hct-25.8*
MCV-104* MCH-31.6 MCHC-30.5* RDW-21.9* Plt Ct-29*
[**2121-7-9**] 07:00AM BLOOD WBC-8.3 RBC-2.42* Hgb-8.0* Hct-25.0*
MCV-103* MCH-33.2* MCHC-32.2 RDW-20.9* Plt Ct-38*
[**2121-6-12**] 07:45PM BLOOD PT-19.2* PTT-39.5* INR(PT)-1.8*
[**2121-6-13**] 10:25AM BLOOD PT-21.1* INR(PT)-2.0*
[**2121-7-8**] 05:00AM BLOOD PT-20.4* PTT-56.1* INR(PT)-1.9*
[**2121-7-9**] 07:40AM BLOOD PT-20.4* PTT-50.5* INR(PT)-1.9*
[**2121-7-9**] 07:00AM BLOOD Glucose-207* UreaN-29* Creat-5.1*# Na-134
K-3.7 Cl-94* HCO3-32 AnGap-12
[**2121-7-8**] 05:00AM BLOOD Glucose-226* UreaN-20 Creat-4.0*# Na-136
K-3.6 Cl-94* HCO3-30 AnGap-16
[**2121-6-11**] 09:00AM BLOOD UreaN-44* Creat-3.1* Na-137 K-5.1 Cl-110*
HCO3-20* AnGap-12
[**2121-6-12**] 07:45PM BLOOD Glucose-110* UreaN-48* Creat-3.7* Na-134
K-5.8* Cl-110* HCO3-18* AnGap-12
[**2121-6-16**] 05:10AM BLOOD Glucose-102 UreaN-61* Creat-7.0* Na-139
K-5.0 Cl-104 HCO3-18* AnGap-22*
[**2121-6-11**] 09:00AM BLOOD ALT-30 AST-73* AlkPhos-156* TotBili-3.6*
[**2121-6-15**] 06:55AM BLOOD ALT-21 AST-52* AlkPhos-79 TotBili-8.2*
[**2121-7-7**] 07:25AM BLOOD ALT-14 AST-55* AlkPhos-159* TotBili-5.8*
[**2121-7-9**] 07:00AM BLOOD ALT-11 AST-45* AlkPhos-154* TotBili-6.3*
[**2121-7-2**] 06:20AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2121-7-2**] 06:33PM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2121-7-9**] 07:00AM BLOOD Calcium-10.1 Phos-3.7 Mg-2.3
[**2121-7-8**] 05:00AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.2
[**2121-7-7**] 07:25AM BLOOD Albumin-3.6 Calcium-10.4* Phos-4.1 Mg-2.4
[**2121-6-11**] 09:00AM BLOOD Albumin-3.5 Calcium-9.2 Phos-3.8 Mg-2.2
[**2121-6-12**] 07:45PM BLOOD Calcium-9.4 Phos-3.9 Mg-2.4
[**2121-6-13**] 07:10AM BLOOD Albumin-4.4 Calcium-9.5 Phos-4.3 Mg-2.3
[**2121-6-26**] 02:45PM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
[**2121-6-26**] 12:24PM BLOOD C3-32* C4-6*
[**2121-6-17**] 10:50AM BLOOD HIV Ab-NEGATIVE
[**2121-6-26**] 02:45PM BLOOD HCV Ab-POSITIVE*
[**2121-6-12**] 09:44PM URINE Color-Amber Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2121-6-14**] 05:24AM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.017
[**2121-6-12**] 09:44PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-TR
[**2121-6-14**] 05:24AM URINE Blood-LG Nitrite-NEG Protein-500
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-MOD
[**2121-6-12**] 09:44PM URINE RBC-0-2 WBC-[**4-30**]* Bacteri-OCC Yeast-OCC
Epi-[**4-30**]
[**2121-6-14**] 05:24AM URINE RBC-[**1-23**]* WBC-21-50* Bacteri-MOD Yeast-MOD
Epi-21-50
[**2121-6-14**] 05:24AM URINE Hours-RANDOM Creat-175 Na-26 TotProt-730
Prot/Cr-4.2*
[**2121-6-12**] 09:44PM URINE Hours-RANDOM Creat-242 Na-25 Cl-15
[**2121-6-13**] 12:31PM ASCITES WBC-33* RBC-9400* Polys-15* Lymphs-36*
Monos-0 Mesothe-1* Macroph-48*
[**2121-6-13**] 12:31PM ASCITES TotPro-2.0 Glucose-148 LD(LDH)-68
Albumin-1.3
All Blood Cultures were (-)
Paracentesis Culture (-)
C. Diff testing x2 (-) [**6-13**], [**7-3**]
[**2121-6-26**] 2:45 pm IMMUNOLOGY
**FINAL REPORT [**2121-6-27**]**
HCV VIRAL LOAD (Final [**2121-6-27**]):
472,000 IU/mL.
[**2121-7-2**] 2:12 pm MRSA SCREEN
**FINAL REPORT [**2121-7-5**]**
MRSA SCREEN (Final [**2121-7-5**]): No MRSA isolated.
[**Known lastname **] [**Last Name (LF) **],[**Known firstname **] [**Medical Record Number 105778**] F 54 [**2066-12-15**]
Radiology Report RENAL U.S. Study Date of [**2121-6-13**] 3:18 PM
[**Last Name (LF) 1383**],[**First Name3 (LF) 1382**] MED FA10 [**2121-6-13**] 3:18 PM
RENAL U.S. Clip # [**Clip Number (Radiology) 105779**]
Reason: INCREASED CREATINE, RENAL FAILURE WORKUP
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with ESLD and acute on chronic renal
failure
REASON FOR THIS EXAMINATION:
Renal failure worup
Final Report
EXAM: Renal ultrasound obtained [**2121-6-13**].
HISTORY: A 54-year-old woman with end-stage liver disease and
acute on
chronic renal failure.
TECHNIQUE: Multiple static grayscale images through the abdomen
were obtained
and submitted for evaluation.
Findings: Note is made of a significant amount of ascites. The
liver is
shrunken and coarse in echotexture with nodularity, consistent
with the known
history of cirrhosis and end-stage liver disease.
The right kidney measures 9.6 cm in size. A 2.3 x 2.1 x 2.3 cm
anechoic
structure along the upper pole of the right kidney demonstrates
posterior
enhancement and is most consistent with a simple cyst. There is
no evidence
of hydronephrosis or renal calculi within the right kidney.
The left kidney measures 9.6 cm in size. There is no
hydronephrosis, calculi
or definite renal masses identified.
The bladder is distended with urine and is unremarkable in
appearance.
IMPRESSION:
1. Unremarkable ultrasound examination of the kidneys with a
simple cyst in
the upper pole of the right kidney.
2. Ascites.
3. Shrunken, nodular and coarsened echotexture of the kidney,
most consistent
with cirrhosis/end-stage liver disease.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 105780**] [**Name (STitle) 105781**]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: FRI [**2121-6-13**] 4:59 PM
Imaging Lab
[**Known lastname **] [**Last Name (LF) **],[**Known firstname **] [**Medical Record Number 105778**] F 54 [**2066-12-15**]
Radiology Report PORTABLE ABDOMEN Study Date of [**2121-6-15**] 8:09 AM
[**Last Name (LF) 1383**],[**First Name3 (LF) 1382**] MED FA10 [**2121-6-15**] 8:09 AM
PORTABLE ABDOMEN Clip # [**Clip Number (Radiology) 105782**]
Reason: abdominal pain
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with ESLD and new ARF with new abdominal
pain
REASON FOR THIS EXAMINATION:
abdominal pain
Final Report
ABDOMEN FILM ON [**6-15**]
`Abdominal pain.
REFERENCE EXAM: [**2120-5-11**]
Gas-filled loops of small bowel are seen displaced medially
within the abdomen
consistent with the patient's known ascites. There is no dilated
loops of
small bowel to suggest obstruction. There is a single supine
film, is not
sufficient to assess for free air.
DR. [**First Name (STitle) **] [**Doctor Last Name **]
Approved: SUN [**2121-6-15**] 2:07 PM
Imaging Lab
[**Known lastname **] [**Last Name (LF) **],[**Known firstname **] [**Medical Record Number 105778**] F 54 [**2066-12-15**]
Radiology Report CT ABDOMEN W/O CONTRAST Study Date of [**2121-6-15**]
11:00 AM
[**Last Name (LF) 1383**],[**First Name3 (LF) 1382**] MED FA10 [**2121-6-15**] 11:00 AM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST Clip #
[**Clip Number (Radiology) 105783**]
Reason: Eval for appendicitis
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with Hep C cirrhosis, recent diagnostic
para to RLQ (no SBP),
now with acute RLQ pain/rebound
REASON FOR THIS EXAMINATION:
Eval for appendicitis
CONTRAINDICATIONS FOR IV CONTRAST:
worsening renal failure;worsening renal failure
Provisional Findings Impression: MKjd SUN [**2121-6-15**] 5:56 PM
PFI: Appendix is normal in appearance. Findings consistent with
cirrhosis
and portal hypertension. Findings also suggest congestive heart
failure.
Gallbladder sludge.
Final Report
EXAM: CT abdomen and pelvis without contrast obtained [**2121-6-15**].
HISTORY: 54-year-old woman with hepatitis C cirrhosis status
post right lower
quadrant paracentesis, now presenting with acute right lower
quadrant pain.
TECHNIQUE: Unenhanced transaxial images from the lung bases
through the
pelvis were obtained with routine protocol.
FINDINGS:
There is a small right pleural effusion. There is diffuse
ground-glass
appearance noted at the lung bases. Also seen is cardiomegaly.
There is
distention of the IVC and diffuse body wall edema. The
constellation of these
findings may be related to fluid overload/congestive heart
failure.
The liver is shrunken and nodular in contour, a morphology
consistent with
cirrhosis. There is a significant amount of ascites and free
pelvic fluid.
The spleen is markedly enlarged. These findings are likely
related to portal
hypertension.
Hyperdense material within the dependent portion of the
gallbladder is most
consistent with sludge. The pancreas and adrenal glands are
unremarkable in
appearance. Low attenuating lesion within the right kidney with
thin
peripheral calcifications is noted, likely representing a renal
cyst.
Otherwise, the kidneys are unremarkable in appearance.
There is diffuse thickening of the wall of the right colon,
which is commonly
identified in patients with liver disease. No evidence of bowel
obstruction.
The appendix is visualized, filled with contrast and
unremarkable in
appearance.
There is diastasis of the rectus abdominis muscle.
Abdominal aorta has a normal course and caliber with scattered
calcified
atherosclerotic plaque.
A few nonenlarged porta hepatis and gastrohepatic lymph nodes
are likely
reactive in etiology. No pathologically-enlarged mesenteric,
retroperitoneal
or intraperitoneal lymphadenopathy is identified.
There is free fluid within the pelvis, with fluid extending into
the inguinal
canals bilaterally.
Osseous structures are grossly unremarkable in appearance.
IMPRESSION:
1. The appendix is normal in appearance.
2. Cirrhosis with findings consistent with portal hypertension,
including
large volume ascites..
3. Cardiomegaly, right pleural effusion. Hazy ground-glass
appearance to the
lungs, distended IVC and body wall edema, all suggesting
congestive heart
failure.
[**Known lastname **] [**Last Name (LF) **],[**Known firstname **] [**Medical Record Number 105778**] F 54 [**2066-12-15**]
Radiology Report MR HEAD W/O CONTRAST Study Date of [**2121-7-1**]
2:09 PM
[**Last Name (LF) 1383**],[**First Name3 (LF) 1382**] MED FA10 [**2121-7-1**] 2:09 PM
MR HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 105784**]
Reason: Please eval for acute ischemic stroke or hemorrhage
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with HCV, ESL, ESRD on HD awaiting
liver/kidney [**Hospital **].
Acute MS change after fall, please eval for acute ischemic
stroke or hemorrhage
REASON FOR THIS EXAMINATION:
Please eval for acute ischemic stroke or hemorrhage
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: A 54-year-old woman with cirrhosis, awaiting liver
and kidney
[**Hospital **], who has an acute mental status change status post
fall.
COMPARISON: Non-contrast head CTs performed earlier on the same
day are
available for correlation.
TECHNIQUE: Sagittal T1-weighted and axial T2-weighted, FLAIR,
[**Hospital **] echo,
and diffusion-weighted images of the head were obtained.
FINDINGS: There are numerous small foci of slow diffusion
involving the
cortex and white matter of the cerebral hemispheres, the
lentiform nuclei, the
right cerebellar peduncle, and the cerebellum bilaterally. These
are
consistent with acute infarctions. Since multiple bilateral
vascular
territories are involved, the etiology is likely embolic.
Multiple small T2
hyperintensities are also seen in the supratentorial white
matter, without
associated diffusion abnormalities, likely related to chronic
small vessel
ischemic disease. The ventricles and sulci are normal in size
and
configuration, without evidence of cerebral edema or cerebral
atrophy. A
portion of the flow void of the cavernous right internal carotid
artery is
poorly visualized, most likely due to volume averaging.
A mucous retention cyst is again seen in the left maxillary
sinus.
IMPRESSION: Numerous small acute infarctions throughout the
supratentorial
and infratentorial brain, in multiple vascular territories,
suggestive of
central embolic etiology.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **] [**Last Name (LF) **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 105785**]TTE
(Complete) Done [**2121-7-2**] at 11:14:06 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Last Name (LF) 1383**], [**First Name3 (LF) 1382**]
[**Hospital1 18**]-Division of Gastroenterol
[**Last Name (NamePattern1) 77317**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2066-12-15**]
Age (years): 54 F Hgt (in): 61
BP (mm Hg): 90/46 Wgt (lb): 165
HR (bpm): 62 BSA (m2): 1.74 m2
Indication: Cerebrovascular event/TIA. Source of embolism.
ICD-9 Codes: 435.9, 424.0, 424.2
Test Information
Date/Time: [**2121-7-2**] at 11:14 Interpret MD: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**],
MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **], RDCS
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: Saline Tech Quality: Adequate
Tape #: 2009W0-0:00 Machine: Other
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.1 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 5.1 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.1 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness:
1.1 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:
1.0 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension:
3.9 cm <= 5.6 cm
Left Ventricle - Systolic Dimension:
2.7 cm
Left Ventricle - Fractional Shortening:
0.31 >= 0.29
Left Ventricle - Ejection Fraction:
>= 60% >= 55%
Left Ventricle - Stroke Volume:
73 ml/beat
Left Ventricle - Cardiac Output:
4.50 L/min
Left Ventricle - Cardiac Index:
2.59 >= 2.0 L/min/M2
Aorta - Sinus Level: 2.0 cm <= 3.6 cm
Aorta - Ascending: 2.7 cm <= 3.4 cm
Aortic Valve - Peak Velocity:
*2.1 m/sec <= 2.0 m/sec
Aortic Valve - Peak [**Last Name (NamePattern1) 21888**]:
18 mm Hg < 20 mm Hg
Aortic Valve - Mean [**Last Name (NamePattern1) 21888**]:
10 mm Hg
Aortic Valve - LVOT VTI:
32
Aortic Valve - LVOT diam:
1.7 cm
Mitral Valve - E Wave: 1.1 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A ratio: 1.38
Mitral Valve - E Wave deceleration time: *286 ms 140-250 ms
[**First Name (Titles) **] [**Last Name (Titles) 21888**] (+ RA = PASP):
20 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2121-3-11**].
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A
catheter or pacing wire is seen in the RA and extending into the
RV. PFO is present. Right-to-left shunt across the interatrial
septum at rest. Increased IVC diameter (>2.1cm) with <35%
decrease during respiration (estimated RA pressure (10-20mmHg).
LEFT VENTRICLE: Normal LV wall thickness, cavity size and
regional/global systolic function (LVEF >55%). Estimated cardiac
index is normal (>=2.5L/min/m2). No resting LVOT [**Year (4 digits) **].
RIGHT VENTRICLE: Moderately dilated RV cavity. Normal RV
systolic function. [Intrinsic RV systolic function likely more
depressed given the severity of TR]. Abnormal diastolic septal
motion/position consistent with RV volume overload.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
Minimal AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Mild thickening of mitral
valve chordae. Mild to moderate ([**11-22**]+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets.
Moderate to severe [3+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: Contrast study was performed with 1 iv
injection of 8 ccs of agitated normal saline at rest.
Echocardiographic results were reviewed by telephone with the
houseofficer caring for the patient. Bilateral pleural
effusions. Ascites.
Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. A patent foramen ovale is present wsith
right-to-left shunt of agitated saline across the interatrial
septum at rest. The estimated right atrial pressure is
10-20mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). The
estimated cardiac index is normal (>=2.5L/min/m2). The right
ventricular cavity is moderately dilated with normal free wall
contractility. [Intrinsic right ventricular systolic function is
likely more depressed given the severity of tricuspid
regurgitation.] There is abnormal diastolic septal
motion/position consistent with right ventricular volume
overload. The aortic valve leaflets (3) are mildly thickened.
There is a minimally increased [**Month/Day (2) **] consistent with minimal
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild to moderate ([**11-22**]+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is a trivial/physiologic pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2121-3-11**], the severity of tricuspid regurgitation is increased
and the right ventricular cavity is now dilated. Minimal aortic
stenosis is also now suggested.
Is there a history to suggest pulmonary embolism as an
explanation for RVE/TR and cerebral infarcts?
IMPRESSION:
CLINICAL IMPLICATIONS:
The patient has mild aortic stenosis. Based on [**2117**] ACC/AHA
Valvular Heart Disease Guidelines, a follow-up echocardiogram is
suggested in 3 years.
Based on [**2118**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Compared with the prior study (images reviewed) of [**2121-3-11**]
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2121-7-2**] 14:24
?????? [**2114**] CareGroup IS. All rights reserved.
[**Known lastname **] [**Last Name (LF) **],[**Known firstname **] [**Medical Record Number 105778**] F 54 [**2066-12-15**]
Radiology Report CAROTID SERIES COMPLETE PORT Study Date of
[**2121-7-2**] 2:51 PM
[**Last Name (LF) 1383**],[**First Name3 (LF) 1382**] MED FA10 [**2121-7-2**] 2:51 PM
CAROTID SERIES COMPLETE PORT; [**Last Name (un) **] DUP EXTEXT BIL (MAP/DVT) P
Clip # [**Clip Number (Radiology) 105786**]
Reason: Please eval for stenosis and thrombus
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with HCV cirrhosis and acute on chronic
renal insufficiency,
now w/ multiple embolic strokes on MRI.
REASON FOR THIS EXAMINATION:
Please eval for stenosis and thrombus
Provisional Findings Impression: [**First Name9 (NamePattern2) 79381**] [**Doctor First Name **] [**2121-7-3**] 11:20 AM
PFI:
No evidence of deep venous thrombosis in the upper extremities.
No evidence of internal carotid artery stenosis on the right
side. Less than
40% stenosis of the left internal carotid artery.
Final Report
HISTORY: 54-year-old woman with cirrhosis and PE. Upper
extremity DVT is
suspected.
TECHNIQUE: Evaluation of the deep veins in the bilateral upper
extremities
was performed with B-mode, color and spectral Doppler
ultrasound.
FINDINGS: Normal compressibility and flow was seen in the
bilateral internal
jugular, subclavian, axillary, and brachial veins. Also normal
augmentation
and phasicity was noticed.
COMPARISON: None available.
IMPRESSION: No evidence of deep venous thrombosis in the upper
extremities.
HISTORY: 54-year-old lady with multiple embolic strokes. Duplex
scan of the
carotid arteries is requested.
TECHNIQUE: Evaluation of the bilateral extracranial carotid
arteries was
performed with B-mode, color and spectral Doppler ultrasound.
FINDINGS: A minimal amount of plaque was seen in the left
internal carotid
artery, with B-mode ultrasound.
On the right side, peak systolic velocities were 58 cm/sec for
the internal
carotid artery, 70 cm/sec for the common carotid artery and 66
cm/sec for the
external carotid artery.
The right ICA/CCA ratio was 0.82.
On the left side, peak systolic velocities were 87 cm/sec for
the ICA, 71
cm/sec for the CCA and 100 cm/sec for the ECA. The left ICA/CCA
ratio was
1.2.
Both vertebral arteries presented antegrade flow.
COMPARISON: None available.
IMPRESSION:
1. No evidence of internal carotid artery stenosis on the right.
2. Less than 40% stenosis of the left internal carotid artery.
DR. [**First Name (STitle) **] [**Name (STitle) **]
Approved: [**Doctor First Name **] [**2121-7-3**] 3:32 PM
Imaging Lab
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **] [**Last Name (LF) **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 105787**]Portable TEE (Congenital) Done [**2121-7-3**] at 3:50:39 PM
FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) **], Critical Care & [**Last Name (un) 9368**]
[**First Name (Titles) **] [**Last Name (Titles) **]
[**Location (un) 830**], E/KS-B23
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2066-12-15**]
Age (years): 54 F Hgt (in): 65
BP (mm Hg): 108/53 Wgt (lb): 160
HR (bpm): 54 BSA (m2): 1.80 m2
Indication: Cerebellar embolic strokes. Evaluate for cardiac
source of embolus.
ICD-9 Codes: 423.9, 424.0, 745.5
Test Information
Date/Time: [**2121-7-3**] at 15:50 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
Test Type: Portable TEE (Congenital) Son[**Name (NI) 930**]: Cardiology
Fellow
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Adequate
Tape #: 2009W004-2:44 Machine: Vivid i-4
Sedation: Versed: 1 mg
Fentanyl: 37.5 mcg
Patient was monitored by a nurse throughout the procedure
Echocardiographic Measurements
Results Measurements Normal Range
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Dilated RA. Dynamic interatrial
septum. PFO is present. Right-to-left shunt across the
interatrial septum at rest.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: No atheroma in aortic arch. Simple atheroma in descending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
masses or vegetations on aortic valve. No AR.
MITRAL VALVE: No mass or vegetation on mitral valve. Mild mitral
annular calcification. Mild thickening of mitral valve chordae.
Calcified tips of papillary muscles. Mild to moderate ([**11-22**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. No mass or vegetation on tricuspid valve.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Small pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**]
throughout the procedure. The patient was monitored by a nurse
in [**Last Name (Titles) 9833**] throughout the procedure. Local anesthesia was
provided by benzocaine topical spray. The patient was sedated
for the TEE. Medications and dosages are listed above (see Test
for the patient was notified of the echocardiographic results by
e-mail. Echocardiographic results were reviewed with the
houseofficer caring for the patient.
Conclusions
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage. The right atrium is
dilated. A patent foramen ovale is present. A right-to-left
shunt across the interatrial septum is seen at rest. Overall
left ventricular systolic function is normal (LVEF>55%). with
normal free wall contractility. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) are
mildly thickened. No masses or vegetations are seen on the
aortic valve. No aortic regurgitation is seen. No mass or
vegetation is seen on the mitral valve. Mild to moderate ([**11-22**]+)
mitral regurgitation is seen. There is a small pericardial
effusion.
IMPRESSION: No intracardiac thrombus or valvular vegetations
seen. Mild to moderate mitral regurgitation. Patent foramen
ovale with right to left shunt at rest.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting physician
[**Last Name (NamePattern4) **] [**2121-7-3**] 16:49
?????? [**2114**] CareGroup IS. All rights reserved.
[**Known lastname **] [**Last Name (LF) **],[**Known firstname **] [**Medical Record Number 105778**] F 54 [**2066-12-15**]
Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study
Date of [**2121-7-2**] 4:39 PM
[**Last Name (LF) **],[**First Name3 (LF) **] F. MED MICU-7 [**2121-7-2**] 4:39 PM
CTA CHEST W&W/O C&RECONS, NON- Clip # [**Clip Number (Radiology) 105788**]
Reason: please eval for PE and also please time contrast for
vessel
[**Hospital 93**] MEDICAL CONDITION:
54 year old woman with cirrhosis and HRS/HD now with new
embolic cva as well as
PFO and right heart strain on echo.
REASON FOR THIS EXAMINATION:
please eval for PE and also please time contrast for vessel
evaluation.
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: SBNa WED [**2121-7-2**] 9:52 PM
Pulmonary vasculature engorgement. No definite PE. ? filliing
defect in RUL
thought to be a in pulm vein (402b, 32). Bilateral atelectasis.
Contrast
refluxing into IVC likely c/w right heart failure. Large amount
of ascites.
Cirrhotic appearing liver. Catheter tip in RA extending into
IVC.
Wet Read Audit # 1 SBNa WED [**2121-7-2**] 7:33 PM
Pulmonary vasculature engorgement. No definite PE. Bilateral
atelectasis.
Contrast refluxing into IVC likely c/w right heart failure.
Large amount of
ascites. Cirrhotic appearing liver.
Wet Read Audit # 2 SBNa WED [**2121-7-2**] 9:50 PM
Pulmonary vasculature engorgement. No definite PE. ? filliing
defect
in RUL thought to be a in pulm vein (402b, 32). Bilateral
atelectasis.
Contrast refluxing into IVC likely c/w right heart failure.
Large amount of
ascites. Cirrhotic appearing liver.
Final Report
PROCEDURE: CTA chest with and without contrast and
reconstructions.
REASON FOR EXAM: 54-year-old woman with cirrhosis and
hemodialysis. New
embolic CVA, as well as PFO and right heart strain on echo.
TECHNIQUE: MDCT axial images of the chest were obtained at full
expiration
using a low-dose technique without contrast followed by a full
full-dose
technique at full inspiration after a rapid bolus of 100 mL
Optiray contrast
with multiplanar reformats.
No previous CT pulmonary angiogram was available for comparison.
FINDINGS: There is a tiny subsegmental filling defect in the
left lower lobe
(3:46), consistent with a small pulmonary embolism.
No aortic dissection or aneurysm.
The heart is markedly enlarged and there is enlargement of the
pulmonary
artery which is associated with tortuosity of the subsegmental
pulmonary
arteries and distal tapering. There is also evidence of right
heart strain
with bowing of the intraventricular septum into the left
ventricle and
enlargement of the right atrium and right ventricle. A
hemodialysis catheter
passes through the right side of the heart with its tip in the
distal IVC. No
pericardial effusion.
Left upper and lower lobe atelectasis is noted, the lungs are
otherwise clear.
Airways are widely patent to the subsegmental levels.
In the limited views of the upper abdomen, the liver has a
nodular outline
consistent with cirrhosis and there is extensive intra-abdominal
ascites.
Review of the bones does not reveal any destructive or sclerotic
bone lesions.
IMPRESSION:
1. Small left lower lobe subsegmental pulmonary embolism.
2. Pulmonary arterial hypertension with right heart strain
manifested by
enlargement of the right atrium and ventricle with bowing of the
intraventricular septum into the left ventricle. Contrast is
also seen to
reflux into the IVC and azygos.
3. Cirrhosis with diffuse intra-abdominal ascites.
Dr [**Last Name (STitle) **] [**Name (STitle) **] contact[**Name (NI) **]
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: FRI [**2121-7-4**] 10:33 AM
Imaging Lab
Brief Hospital Course:
# Hepatorenal Syndrome: Patient was admitted because of an
elevated creatinine on laboratory testing. Her Cr was 5.1 on
admission and it peaked at 6.0 on [**6-13**]. She was treated with
increasing doses of midodrine and octreotide for HRS but her
kidney function never recovered. She was subsequently started on
hemodialysis. A tunneled right subclavian catheter was placed
on [**6-23**] which has been used for this purpose since. Her schedule
is MWF, she has had no issues w/ hypotension during her
dialysis.
.
# HCV Cirrhosis: Pt has a history of HCV requiering intermittent
U/S guieded paracentesis for abdominal discomfort because of
increasing ascites. She was high on the [**Month/Day (4) **] list after
developing HRS with a MELD score ranging in the low to mid 30s.
After being on dialysis for 2 weeks she was evaluated by the
renal [**Month/Day (4) **] list by [**Month/Day (4) **] nephrology and she was
approved for a kidney as well. She was started on rifaxamin and
lactulose after an episode of AMS that was thought to be due to
her CVA with a component of hepatic encephalopathy. She is
currently deactivated from the liver/kidney [**Month/Day (4) **] list
awaiting recovery from ischemic stroke.
.
# CVA: After being started on HD patient was stable having no
issues, just awaiting [**Month/Day (4) **]. As she was high on the list it
was decided that she should stay in the hospital until matching
liver/kidney were obtained so she could undergo surgery. On [**7-1**]
she suffered a fall while going to the bathroom in the middle of
the night. She being assisted by a nurse [**First Name (Titles) 1023**] [**Last Name (Titles) 105789**] the
fall and reported that she hit her head. A head CT was obtained
which was (-) for bleed. On the morning of [**7-2**] she was found
to be unresponsive and to have some neurological deficits. An
MRI brain was obtained which was again (-) for bleed but she was
found to have had multiple ischemic infarts distributed evenly
accross the brain suggesting an embolic shower from unknown
source. She underwent TTE, TEE, carotid dopplers, LE dopplers
and CTA. Despite this work up no source for the emboli was
found, but she was found to have a PFO which could have
permitted venous emboli to cross from RA to LA potentially
causing the strokes. Per cardiology attending [**Location (un) 1131**] the TEE,
there was no apparent thrombus on the HD line tip by TEE.
Cardiology was consulted for eval for closure of the PFO but
they thought that this would not be appropriate as pt w/
multiple medical problems and she would need long term
anticoagulation post-procedure which is contraindicated at the
time. She was also not given a IVC filter since no source of
thrombus was found and it would develop clot on the filter
without anticoagulation. Pt has since improved, is undergoing
in patient PT and passed speech and swallow testing so is taking
PO.
.
# AMS/Hypotension: On morning of [**7-3**] she was found to be
unresponsive and hypotensive. This was thought to be due to her
recent CVA w/ possible component of hepatic encephalopathy and
dehydration as pt was NPO at the time. She was transfered to the
MICU where her hypotension responded to IVF hydration. She was
started on lacutlose and rifaxamin and her mental status
improved. She returned to the floor after ~2 days in the MICU.
She had no more episodes of AMS and her BP has remained stable
at her baseline.
.
# PE: Pt was found to have a small subsegmental LLL PE while
being worked up for embolic source of her CVA. Her respiratory
status was never afected by the PE. She was not started on
anticoagulation as she is at risk for bleeding because of her
ESLD and there is difficulty determine therapeutic levels since
she already has an elevated PTT from her ESLD.
.
# Ascites: Pt requiered 2 therapeutic paracentesis during this
admission. Her last one was done on the day of discharge,
[**2121-7-9**], and she received albumin post-procedure. She has a
history of SBP in the past and is on Cefpodoxime prophylaxis for
this (changed from ciprofloxacin as this caused long QT on pt).
.
# Epistaxis: Pt had an episode of epistaxis after HD on [**7-5**]. It
was at first unresponsive to pressure. ENT was consulted who
suggested Afrin spray and application of more pressure which
stopped the bleeding. Patient had no more episodes of epistaxis.
.
# Diabetes mellitus: Pt has a prior history of DM that had been
well controlled w/ diet modifications as an outpatient. Her
blood glucose has been increasingly hard to control on ISS.
Glargine 10 units was started on [**7-6**], it has been given in the
mornings and received on the morning of discharge. She should
switched to night time dosing. Please titrate her glargine and
humalog sliding scale accordingly.
.
# Coccygeal wound:
Care for as such:
Wound care:
Site: coccyx/sacral
Type: Pressure ulcer
Cleansing [**Doctor Last Name 360**]: Commercial cleanser
Change dressing: Other
Comment: please apply mepilex border, q3days prn
.
# Code: FULL
Medications on Admission:
Cholecalciferol 800 Daily
Calcium Carbonate 500 mg TID
Fluticasone Nasal
Clotrimazole 10 mg QID
Pantoprazole 40 mg Q24H
Nadolol 20 mg DAILY
Ferrous Sulfate 325 mg TID
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary:
Hepatitis C Virus related cirrhosis (contracted while working as
lab tech)
portal hypertension
ascites
hepatorenal syndrome
embolic stroke
pulmonary embolus
patent foramen ovale
DM
Secondary:
h/o SBP, s/p thx abx and ppx cipro
hypertension
mitral regurgitation
[**Hospital1 105777**] [**Hospital1 32050**] hernia repair [**5-11**] by Dr. [**Last Name (STitle) **]
Discharge Condition:
improved, stable
Discharge Instructions:
You were seen at [**Hospital1 18**] for liver failure and kidney failure.
Your kidneys never recovered so you had to be started on
hemodialysis. You were initially listed for liver and kidney
[**Hospital1 **]. It was decided that it would be better for you to
stay in the hospital while you waited for a potential
[**Hospital1 **]. While in the hospital suffered from embolic strokes
related to a congenital hole in your heart. Because we did not
find a source for the clots, and because of your liver disease,
we did not think you were a good candidate for anticoagulation
or filter to prevent other clots. You also had a small amount
of the clot go to your lungs without significant impairment of
your lung function. As a result of your stroke you are curretnly
not on the [**Hospital1 **] list. You are being discharged to undergo
rehab to assess how much function you can regain after your
stroke and after this will be re-evaluated for re-enlisting on
the [**Hospital1 **] list.
Please return to the ED or call your PCP if you experience:
- worsening confusion
- fever greater than 100.4 degrees F
- bloody stool or black tarry stool
- weakness/numbness/tingling anywhere in your body
- difficulty speaking
- visual changes
- facial drooping
- chest pain
- shortness of breath
Followup Instructions:
please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 3329**]),
within two weeks of discharge from your rehab.
You have an appointment scheduled with Dr. [**Last Name (STitle) 497**] in the
[**Last Name (STitle) **] [**Hospital 1389**] CLINIC Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2121-8-6**] 8:40
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
[
"5845",
"40391",
"25000",
"4240"
] |
Admission Date: [**2172-3-27**] Discharge Date: [**2172-3-28**]
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
respiratory distress, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] yo Polish-speaking W with CAD, CHF (EF 30-40%), DM2, HTN,
Dementia, and hx of Nephrolithiasis who was brought in from
[**Hospital3 2558**] for evaluation of hypotension (80s/40s) and
hypoxia that occurred this morning. Per report, yesterday she
appeared tachypneic and her mental status was noted to be
altered at some time "between [**2-28**] PM" yesterday.
.
In the ED, initial vs were: T 102.2 P 120 BP 157/121 R 20 O2 sat
90% on 15L NRB. Labs were notable for Lactate 11, WC 24.5, Hct
48, BNP 18,766, Cr 2.2, and K of 8.3 (+ hemolysis; repeat 4).
Urinalysis revealed significant pyuria and glucosuria. CXR
showed B/L small effusions, bibasilar opacities, and mild
vascular congestion. She was given Vancomycin and Levaquin for
presumed PNA. EKG was sinus tachycardia with no evidence of
acute ischemia.
.
She appeared dry and her BP fell to 80s/50s, so was given 2L of
NS with subsequent improvement to 107/55. Central line was not
placed. She has 2 PIVs for access. Additionally, BiPAP was
attempted, but Pt would not tolerate [**1-22**] nausea and vomiting.
She is DNR/DNI.
.
On admission to the [**Hospital Unit Name 153**] the patient appeared to tachypneic and
working hard to breathe.
.
Review of sytems: unable to obtain at this moment [**1-22**] language
barrier
Past Medical History:
Past Medical History: (per OMR)
1. Type 2 diabetes mellitus
2. HTN
3. CAD s/p MI in [**2163**] and [**2167**]
4. Dementia with question of delusional component
5. OA
6. Gout
7. Osteoporosis
8. Glaucoma s/p bilat eye surgeries
9. Dysphagia with liquids (drinks prethickened liquids)
10. Hx of Nephrolithiasis s/p lithotripsy, ureteral stent [**2167**]
Social History:
(per OMR) The patient lives at [**Hospital3 2558**]. She is DNR/DNI.
No tobacco,
ETOH, or drugs. No family, has POA: [**Name (NI) **] [**Name (NI) 92883**] [**Telephone/Fax (1) 92884**].
Family History:
Non-contributory
Physical Exam:
VS: 96.3, 109, 121/76, 100%
General: alert, unable to check orientation, visibly tachypneic
HEENT: sclera anicteric, dry MM, oropharynx clear
Lungs: diffuse rhonchorous sounds throughout
CV: tachycardic, S1 + S2, unable to appreciate extra sounds
Abdomen: obese, soft, non-tender, bowel sounds present
Ext: thin, warm, no edema
Neuro: face symmetric, moves all extremities
Pertinent Results:
[**2172-3-27**]
-WBC-24.5*# RBC-5.41*# Hgb-15.5# Hct-48.2*# MCV-89 MCH-28.6
MCHC-32.1 RDW-14.2 Plt Ct-289 Neuts-79* Bands-4 Lymphs-12*
Monos-5 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
-Glucose-320* UreaN-54* Creat-2.2*# Na-143 K-8.2* Cl-105
HCO3-14* AnGap-32*
-cTropnT-0.04* CK-MB-2 proBNP-[**Numeric Identifier **]*
-Osmolal-331*
-Lactate-11.6* K-4.2
.
CXR IMPRESSION:
1. Bilateral pleural effusions, left greater than right.
2. Bibasilar and retrocardiac opacities may represent
combination of atelectasis and effusion, left greater than
right; however, infectious process cannot be excluded.
3. Mild pulmonary edema.
Brief Hospital Course:
[**Age over 90 **] yo Woman with hx of CAD, CHF, HTN, DM2, Hx of nephrolithiasis
and dementia presenting with hypoxia and hypotension, admitted
to [**Hospital Unit Name 153**] for continued management. Given poor prognosis despite
aggressive medical therapy, goals of care were transitioned to
focusing on comfort measures.
.
# Goals of Care: Per HCP/POA the patient was DNR/DNI. He wished
for her to remain comfortable and agreed with pursuing
aggressive comfort measures given her poor clinical status and
very small likelihood of meaningful recovery despite aggressive
medical therapy. The patient had a friend visit, who
communicated the news to her sister in [**Name (NI) 36978**]. She received a
morphine drip for control of pain and dyspnea, Tylenol for
fever, and scopolamine patch for secretions. A volunteer sitter
provided the patient company prior to her passing away.
.
# Respiratory Failure: Presented 98% on 15L NRB, appearing
visibly tachypneic and working hard to breathe. BiPAP was
attempted and discontinued secondary to intolerance (nausea and
vomiting). CXR showed bilateral pleural effusions and mild
vascular congestion without definitive focal opacity. She
received Vancomycin and Levaquin in the ED. Also, BNP of 18K;
however, volume status overall appeared down. Unclear etiology
for respiratory failure, but given goals of care to pursue
aggressive comfort measures, dyspnea was treated with a morphine
gtt.
.
# Hypotension: Likely secondary to hypovolemia and/or sepsis
physiology given fever, elevated white count, bands, and
urinalysis reflecting infection as potential source. BCx also
grew GPC. Received Vancomycin and Levaquin in ED. Was
hypotensive to 80s/50s on presentation and responded to fluid
boluses. Central line was not within goals of care. Given goals
of care to pursue aggressive comfort measures, we discontinued
blood draws, antibiotics, and pursued fever and pain control.
.
# Metabolic acidosis: Likely secondary to elevated lactate
(11.6). Urine blood glucose 1000, elevated serum glucose levels,
and severe dehydration so possibly a component of hyperosmotic
non-ketotic acidosis. Given goals of care to pursue aggressive
comfort measures, additional management was not pursued besides
initial fluid resuscitation.
.
# Acute Kidney Injury: No recent baseline. Per records, last Cr
0.7 (in [**2167**]). Given evidence of significant volume depletion in
setting of fever, likely pre-renal etiology. Given goals of care
to pursue aggressive comfort measures, did not pursue additional
management.
.
# Urinary Tract Infection: Significant pyuria on urinalysis. Has
a history of nephrolithiasis s/p lithotripsy and ureteral stents
complicated by urosepsis. Received Vancomycin and Levaquin in
ED. Given current goals of care and very small likelihood that
aggressive medical therapy will help, antibiotics were
discontinued.
.
# Coronary Artery Disease: Hx of prior MI. Trop elevated at
0.04, likely secondary to demand ischemia in setting of poor
renal clearance. Given goals of care to pursue aggressive
comfort measures, did not pursue additional management.
.
Code: DNR/DNI (confirmed)
.
Communication: Power of Attorney [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 92883**] [**Telephone/Fax (1) 92884**]
Medications on Admission:
unclear
Discharge Medications:
not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
septic shock
respiratory distress
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"0389",
"51881",
"78552",
"2762",
"5849",
"5990",
"99592",
"41401",
"4019",
"25000",
"412"
] |
Admission Date: [**2162-2-26**] Discharge Date: [**2162-3-8**]
Date of Birth: [**2084-4-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Coronary artery disease
Major Surgical or Invasive Procedure:
Coronary artery Bypass grafting x 3
History of Present Illness:
This is a 77 year old gentleman who presented to an outside
hospital with exertional chest pain radiating to his left
shoulder, neck and arm. He had a known history of hypertension
but was otherwise healthy. An ekg revealed ST depressions and he
was referred for cardiac catheterization at the outside
hospital. This revealed a right dominant heart with 40% stenosis
of his distal left main, 80% stenosis of his LAD, 40% stenosis
of his left circumflex, and total stenosis of his right coronary
artery. Heparin and integrellin drips were started and he was
transferred to [**Hospital1 18**] for planned coronary artery bypass grafting
Past Medical History:
Hypertension
Social History:
The patient lives alone, denies any alcohol or tobacco use. He
occasionally drives a truck for a living.
Family History:
The patient's father, brother, and sister have had myocardial
infarctions in the past.
Physical Exam:
ON admission:
Afebrile, wt 198 pounds, pulse 79 sinus, BP 91/66, 95% room air
Gen: pleasant elderly male, healthy-appearing, not in pain
HEENT: MMM, EOMI
Neck: no masses, no JVD
CV: RRR, no murmur
Pulm: CTAB
Abd: soft, NT/ND, + BS
Extr: no edema
Pertinent Results:
[**2162-2-26**] 07:19PM BLOOD WBC-9.8 RBC-3.96* Hgb-13.4* Hct-38.4*
MCV-97 MCH-34.0* MCHC-35.0 RDW-13.3 Plt Ct-193
[**2162-2-28**] 05:25AM BLOOD WBC-9.1 RBC-3.76* Hgb-12.6* Hct-35.7*
MCV-95 MCH-33.6* MCHC-35.4* RDW-13.4 Plt Ct-201
[**2162-3-1**] 01:52PM BLOOD WBC-7.9 RBC-2.85* Hgb-9.7* Hct-27.5*
MCV-96 MCH-34.1* MCHC-35.4* RDW-13.3 Plt Ct-135*
[**2162-3-2**] 02:52AM BLOOD WBC-14.0* RBC-3.21* Hgb-11.1* Hct-31.1*
MCV-97 MCH-34.6* MCHC-35.8* RDW-13.3 Plt Ct-210#
[**2162-3-4**] 03:56AM BLOOD WBC-10.2 RBC-2.79* Hgb-9.5* Hct-26.7*
MCV-96 MCH-34.1* MCHC-35.6* RDW-13.3 Plt Ct-230
[**2162-3-5**] 02:54AM BLOOD WBC-8.7 RBC-2.85* Hgb-9.5* Hct-27.5*
MCV-97 MCH-33.4* MCHC-34.5 RDW-13.2 Plt Ct-303
[**2162-3-7**] 05:03AM BLOOD WBC-7.2 RBC-2.82* Hgb-9.6* Hct-27.6*
MCV-98 MCH-33.9* MCHC-34.7 RDW-13.3 Plt Ct-379
[**2162-2-26**] 07:19PM BLOOD PT-12.3 PTT-30.9 INR(PT)-1.1
[**2162-3-5**] 05:00PM BLOOD PT-13.3* PTT-38.6* INR(PT)-1.2*
[**2162-3-6**] 09:35AM BLOOD PT-14.2* PTT-61.3* INR(PT)-1.3*
[**2162-3-7**] 05:03AM BLOOD PT-16.4* PTT-71.8* INR(PT)-1.5*
[**2162-2-26**] 07:19PM BLOOD Glucose-117* UreaN-21* Creat-1.0 Na-139
K-4.0 Cl-106 HCO3-24 AnGap-13
[**2162-3-1**] 06:05AM BLOOD Glucose-121* UreaN-19 Creat-1.1 Na-137
K-3.9 Cl-104 HCO3-24 AnGap-13
[**2162-3-2**] 02:52AM BLOOD UreaN-15 Creat-1.1 Na-137 K-5.3* Cl-107
HCO3-21* AnGap-14
[**2162-3-4**] 05:18PM BLOOD Glucose-100 UreaN-25* Creat-1.2 Na-136
K-4.3 Cl-102 HCO3-24 AnGap-14
[**2162-3-5**] 02:54AM BLOOD Glucose-108* UreaN-27* Creat-1.2 Na-137
K-4.1 Cl-102 HCO3-27 AnGap-12
[**2162-3-7**] 05:03AM BLOOD Glucose-101 UreaN-23* Creat-1.3* Na-138
K-4.6 Cl-102 HCO3-26 AnGap-15
[**2162-2-28**] 05:25AM BLOOD Albumin-3.7
[**2162-3-1**] 06:05AM BLOOD Calcium-8.3* Phos-2.2* Mg-1.8
[**2162-3-2**] 02:52AM BLOOD Phos-3.1 Mg-2.8*
[**2162-3-5**] 02:54AM BLOOD Calcium-8.3* Phos-4.5 Mg-2.1
[**2162-2-26**] CXR: Left lower lobe linear atelectasis/scarring. No
pneumonia or
congestive heart failure.
[**2161-2-27**] Carotid U/S: On the right, peak systolic velocities are
65, 91, 67 in the ICA, CCA, ECA respectively. The ICA to CCA
ratio is 0.7. This is consistent with no stenosis.
On the left, peak systolic velocities are 60, 89, 53 in the ICA,
CCA, ECA
respectively. The ICA to CCA ratio is 0.7. This is consistent
with no
stenosis. There is antegrade flow in both vertebral arteries.
[**2162-3-4**] CXR: There has been interval removal of the Swan-Ganz
catheter. Right-sided central line is seen with the distal tip
overlying the SVC atrial junction. Again seen are median
sternotomy wires. Cardiac and mediastinal and hilar contours
appear relatively unchanged. No chf or infiltrate is detected.
Right- sided linear atelectasis is again noted. Blunting of the
costophrenic angles consistent with small pleural effusions also
appears unchanged.
IMPRESSION: Right-sided central line with distal tip over the
SVC atrial
junction. No evidence of pneumothorax.
[**2162-2-27**] TTE: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. There is mild regional
left ventricular systolic dysfunction with hypokinesis of the
inferobasal wall. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
[**2162-3-1**] TEE: Prebypass
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect is seen
by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is top normal/borderline dilated. No
left ventricular aneurysm is seen. There is mild regional left
ventricular systolic dysfunction. Overall left ventricular
systolic function is low normal (LVEF 50-55%). Resting regional
wall motion abnormalities include mild hypokinesia of the apex
and mid portion of the inferior wall.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The descending thoracic
aorta is mildly dilated. There are simple atheroma in the
descending thoracic aorta.
The aortic valve leaflets appear structurally normal with good
leaflet excursion. There are three aortic valve leaflets. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The mitral annulus measures 3.3 cm. The
MR is central . There is no obvious leaflet pathology. There is
no pericardial effusion.
Post Bypass
LV function somewhat improved. Inferior wall has much better
contractility. RV function is preserved. Aorta intact post
decannulation.
Mild MR persists.
[**2162-2-27**] Urine culture: negative
Brief Hospital Course:
This is a 77 year old gentleman who was transferred from an
outside hospital for planned coronary artery bypass grafting. He
was admitted on [**2162-2-26**] and a heparin and integrelin drip were
started; he had 2 episodes of chest pain spontaneously resolved
with nitroglycerin tablets. He was then taken to the operating
room on [**2162-3-1**] for CABG x 3 (please see the operative report of
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] for full details). He did well in the intial
post-operative course and was extubated in the cardiac intensive
care unit on the night of his operation. He required some
neosynephrine for blood pressure management but this was
eventually weened off. On post-operative day 1 he got out of
bed, tolerated a regular diet, and his chest tubes and swan ganz
catheter were removed. He had a bout of rapid Afib on post-op
day 1 evening and an amiodarone drip was started. He was
transferred to the floor on post-op day 3 and oral amiodarone
was started. He had one more episode of atrial fibrillation on
[**2162-3-6**]. Anticoagulation with heparin drip bridged over to oral
coumadin was started on post-op day 4, with 5 mg of coumadin
given on [**3-7**] and [**3-8**]. He worked with physical therapy and was
deemed satisfactory for home discharge with VNA. All questions
were answered to his satisfaction upon discharge and planned
follow-up with his PCP and cardiac surgery were coordinated.
Medications on Admission:
Lisinopril (dose unknown)
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*10 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day:
400mg [**Hospital1 **] x1 wk then 400mg QD x1wk then 200mg QD.
Disp:*60 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Coumadin 2 mg Tablet Sig: as directed Tablet PO once a day:
2mg on [**3-8**]&11 then as directed by Dr [**First Name (STitle) 1075**].
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Coronary Artery disease s/p CABG x3 (LIMA->LAD, SVG->OM,
SVG->PDA)
PMH: HTN
Discharge Condition:
Stable. Good pain control. Ambulatory. Tolerating POs.
Discharge Instructions:
Take all medicatiosn as prescribe.d Do not drive while taking
narcotics. A visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] you with cardiopulmonary
monitoring and checking your INR for coumadin dosing. Please
contact the office or come to the ER with any worsening
shortness of breath, chest pain, fevers, or drainage from your
incisions. You may shower but no baths or swimming for 3 weeks.
Followup Instructions:
Followup in [**1-30**] weeks with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] (call ofr an
appointment at [**Telephone/Fax (1) 170**])
You should also see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**] within 1-2 days of your
discharge to have your coumadin dosed (as discussed with you in
the hospital)
Completed by:[**2162-3-9**]
|
[
"41071",
"41401",
"9971",
"42731",
"4019"
] |
Admission Date: [**2183-11-10**] Discharge Date: [**2183-11-18**]
Date of Birth: [**2138-12-11**] Sex: F
Service: Neurosurgery
HISTORY OF PRESENT ILLNESS: The patient is a 44 year old
right handed woman with a history of hypertension, vertigo
and migraine headaches, who presents with sudden onset of
severe headache. She was working in this hospital when she
suddenly had sharp pain at the right neck and occipital and
also along the right frontal part of her head. There was a
right eye pressure but she did not have a blurry or double
vision. She also developed diaphoresis and felt lightheaded.
A CT scan of the head revealed a subarachnoid hemorrhage.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for close observation. She had an
angiogram which was negative for an aneurysmal bleed. She
was monitored in the Intensive Care Unit for 24 hours then
transferred to the regular floor, where she continued to be
monitored for a week. She had a repeat angiogram on [**2183-11-7**], which again was negative for aneurysm. She
remained neurologically stable, awake, alert and oriented
times three, moving all extremities with good strength, with
no drift.
DISPOSITION: The patient was discharged to home on [**2183-11-18**] in stable condition with follow-up with Dr. [**Last Name (STitle) 1132**] in
one month.
DISCHARGE MEDICATIONS:
Atenolol 25 mg p.o.q.d.
CONDITION ON DISCHARGE: Stable.
[**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2183-11-18**] 10:50
T: [**2183-11-18**] 13:15
JOB#: [**Job Number 23639**]
|
[
"4019"
] |
Admission Date: [**2190-10-25**] Discharge Date: [**2190-11-5**]
Service: MEDICINE
Allergies:
Metoprolol
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
PEG placement
History of Present Illness:
84 M Russian speaking, h/o CAD (s/p RCA and LAD stenting [**2186**]),
DM2, HTN, CKD, h/o recurrent aspiration PNA, who presents with
acute onset of SOB from NH. Pt was in USOH until yesterday when
he was found to be acutely SOB with sats down to the 80s. His
son was present and provided most of the history. EMS was called
and pt was placed on a NRB with little improvement of his sats.
He was brought to the ED for further management.
.
Of note, pt was recently admitted from [**9-29**] to [**10-13**] for
pneumonia with transient intubation/ICU stay, found to have
pan-sensitive pneumococcus growing from his sputum cultures. He
completed a 10d course of CTX after initial broader coverage. He
was also found to have positive C diff from [**10-13**] and was started
on PO Flagyl x14 days on [**10-14**].
.
In the ED, his VS on arrival were Temp oral 99, rectal 101, HR
108, BP 110/62, RR 26, 97% on NRB. Pt had diffuse rhonchi on
exam. Lactate was 3.3, WBC elevated at 14.8 with 17% bands. CXR
showed new infiltrate in left lower lung. Pt received 1x 1gm IV
Vanco (did not complete this as he developed hives during
infusion), 750mg IV Levo, 1 gram ceftriaxone and 500mg IV
Flagyl. He also received 1300 mg tylenol rectally. Pt refused
nasal suction and BiPAP but O2sats remained stable on NRB. RR
was ranging from 18-38. 1x Albuterol neb was given. HR went up
from the 100s to 122. BP dropped to systolic 78. Pt received 2L
NS with improvement of BP to 122/81. Of note, EKG showed new
lateral TWI. CE with flat CK-MB and Trop of 0.04. Cardiology was
contact[**Name (NI) **] and felt that EKG changes were due to
infection/tachycardia. The decision was made not to intervene
unless EKG changes further. Pt was admitted on NRB to ICU for
further management of suspected pneumonia.
.
On arrival in the ICU, his VS were HR 99, T97.7 ax, 98% on 100%
NRB, R 28, BP 109/59. Via his son, pt was able to tell me that
he was "so-so". He denied chest pain, palp, nausea, vomiting,
abd pain, LE swelling. He has has left sided rib pain since last
admission. Otherwise, ros negative.
Past Medical History:
- CAD s/p RCA and LAD stenting [**2186**].
- PVD - s/p R ICA stent ([**2186**]) with a stable moderate left
internal carotid artery stenosis.
- CKD (baseline cre = 0.9-1.3)
- DM2
- HTN
- hyperlipidemia
- GERD
- h/o radiation to the larynx in the Soviet [**Hospital1 1281**] in the [**2153**]
for presumed laryngeal cancer.
- h/o aspiration pneumonia
- h/o gastrojejunostomy tube; status post aspiration pna
(removed) x 1 [**1-12**] yrs to reduce need for oral feeds and prevent
recurrent pneumonia. Tube fell out and was not replaced in
spring [**2186**] as he had been eating gradually more food and a
trial of oral feeding was chosen. The cause of the aspiration
pneumonia was thought to be disordered swallowing s/p XRT to his
larynx yrs ago in the USSR.
- spinal stenosis - s/p ? recent spinal injection.
- h/o recurrent bronchitis - with restrictive defect on PFTs
[**6-16**].
- h/o falls.
Social History:
40 yrs x 1 ppd tobbacco, denies alcohol, IVDU. lives in [**Location 583**]
(elderly living), former mechanic. At baseline performs own
adls.
Family History:
NC
Physical Exam:
VS: Temp 97.7 ax BP 109/59 HR 99 RR 28 O2sat 98% on 100% NRB
GEN: pleasant, comfortable, NAD, tacchypneic with any movement
HEENT: PERRL, EOMI, anicteric, MM dry, op without lesions
NECK: no supraclavicular or cervical lymphadenopathy, no jvd
RESP: diffuse rhonchi b/l R>L
CV: RR, mildly tacchy S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, cool, good pulses
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout.
sensation grossly intact.
Pertinent Results:
CXR: New airspace opacities within the left lower lung most
consistent with aspiration. Although less likely, pneumonia
should be considered.
.
[**2190-9-30**] TTE - Normal biventricular function. Normal left
ventricular diastolic function. No significant valvular
abnormality seen.
.
EKG: LAD, likely left ant fasicular block, tacchycardic, sinus
rhythm, new lateral ST depression compared to previous EKG.
.
ON ADMISSION LABS:
[**2190-10-25**] 02:30AM BLOOD WBC-14.8* RBC-4.05* Hgb-12.7* Hct-39.4*
MCV-97 MCH-31.3 MCHC-32.1 RDW-14.5 Plt Ct-328
[**2190-10-25**] 02:30AM BLOOD Neuts-71* Bands-17* Lymphs-2* Monos-5
Eos-1 Baso-2 Atyps-0 Metas-1* Myelos-1*
[**2190-10-25**] 02:30AM BLOOD PT-13.7* PTT-25.2 INR(PT)-1.2*
[**2190-10-25**] 02:30AM BLOOD Glucose-324* UreaN-20 Creat-1.5* Na-143
K-4.8 Cl-106 HCO3-21* AnGap-21*
[**2190-10-25**] 02:30AM BLOOD ALT-29 AST-30 CK(CPK)-140 AlkPhos-75
Amylase-92 TotBili-0.3
[**2190-10-25**] 02:30AM BLOOD CK-MB-6 cTropnT-0.04* proBNP-748
[**2190-10-25**] 10:12AM BLOOD CK-MB-6 cTropnT-0.03*
[**2190-10-25**] 02:30AM BLOOD Calcium-8.8 Phos-2.1* Mg-1.1*
[**2190-10-25**] 02:50AM BLOOD Lactate-3.3*
Brief Hospital Course:
A/P:
84 M russian speaking, h/o CAD, NIDDM, HTN, CKD, h/o recurrent
aspiration PNA, who presents acute onset of SOB, found to have
pneumonia.
.
# PNA: Patient readmitted to [**Hospital1 18**] with findings c/w pneumonia
RLL. Patient has longstanding h/o aspiration PNA, but recently
hospitalized with pneumococcal pneumonia that may have been vent
associated [**10-13**]. Started on vanc for MRSA and zosyn for gram
negative, pseudomonas (given ? vent-assoc pna) and anerobic
coverage. All cultures [**Last Name (LF) 5971**], [**First Name3 (LF) **] will complete 8 day total
course of antibiotics given clinical improvement. Yesterday
failed speech/swallow evaluation and pt refuses dobhoff.
Patient maintained on aspiration precations, kept NPO, PPN for
nutrition, and both Surgery and GI were consulted for PEG
placement, with GI proceeding to PEG placement on [**11-2**]. This
was completed without complication and Tube feedings were
resumed.
.
# HTN: Patient normotensive [**10-26**]. Was hypotensive in ED, stable
on arrival in ICU. Hypertensive yesterday to SBP 150s.
Patient's antihypertensive regimen was adjusted to reach a goal
of <130/80.
.
# DM: On admission patienthad AG acidosis and trace ketones with
sugars in 370s. Metoformin held, insulin gtt started. Patient
[**10-25**] transitioned to insulin ssi with BG 90s - 140s. He was
subsequently converted to and titrated on daily glargine
insulin, with sliding scale lispro four times daily.
.
# CAD: s/p RCA and LAD stenting [**2186**]. No CP, patient ruled out
for an MI. Continued ASA, plavix, statin. Beta blockers were
not started due to a history of significant bradycardia per PCP.
.
# Hyperlipidemia: continued statin.
.
# C diff: C diff positive during last admission. Positive stool
test on [**10-13**]. Continued flagyl to complete 14 day course [**10-28**].
.
# ARF - Resolved. Baseline creatinine 1.2-1.3, but recently in
the normal range. Cr up to 2.0 on admission. Likely prerenal,
patient Cr improved with 3 liters fluids. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was
restarted and his serum creatinine remained at baseline.
Medications on Admission:
Medications (from recent DC summary from [**10-13**]):
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours).
5. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
puff Inhalation Q4H (every 4 hours).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Flagyl 500 mg po TID x 10 days prior to admission for C. Dif
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
neb Inhalation Q4H (every 4 hours) as needed.
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed.
9. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day) as needed for constipation.
10. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
12. Insulin Lispro 100 unit/mL Solution Sig: as directed by
sliding scale (included) Units, insulin Subcutaneous QID
insulin.
Discharge Disposition:
Extended Care
Facility:
Meadowbrook - [**Location (un) 2624**]
Discharge Diagnosis:
1. Aspiration pneumonia
2. Chronic aspiration
3. Type 2 diabetes mellitus
4. Hypertension
5. 2-vessel CAD s/p stent
6. Peripheral arterial disease s/p stent
7. Hyperlipidemia
8. GERD
9. s/p radiation therapy to the neck for laryngeal cancer
10. Spinal stenosis
Discharge Condition:
Stable
Discharge Instructions:
Please contact your primary physician if you acutely develop
shortness of breath, fevers, sweats, chills, vomiting or
diarrhea.
Continue standard care for your gastrostomy tube.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2190-11-22**] 9:30
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2191-2-8**] 10:20
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2191-5-31**]
2:00
|
[
"5070",
"5849",
"40390",
"5859",
"25000",
"41401",
"2724",
"53081",
"42789"
] |
Admission Date: [**2100-6-14**] Discharge Date: [**2100-6-23**]
Date of Birth: [**2028-10-27**] Sex: F
Service: Neurology
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 15273**] is a 71-year-old
woman with a past medical history of hypertension, high
cholesterol, thoracic abdominal aortic repair times two,
polymyalgia rheumatica, and giant-cell arteritis.
At baseline, the patient has been unable to do her activities of
daily living due to generalized weakness that started suddenly at
the time of her second thoracic aneurysm repair.
Today she was in her usual state of health and was noted by
her family that while sleeping in a chair, she slumped to the
right at 6 p.m. They tried to wake her up a couple of hours
later. She mumbled a few words a went back to sleep. At 10
p.m. they again tried to arouse her and had difficulty. She
could answer a few simple sentences but she could not open
her eyes. They noticed that she had a left facial droop and
her left side was weak, but she was able to grip their hands
with her hand.
She was brought to [**Hospital 882**] Hospital by ambulance where a
head computed tomography revealed a right thalamic
hemorrhage. She was agitated and received 1 mg of Ativan;
after which she became much worse and more lethargic. Her
blood pressure was erratic; ranging from 83/54 to 183/141.
She was transferred to [**Hospital1 69**]
for further management.
The patient has baseline dementia with Alzheimer's disease
and was admitted to the Intensive Care Unit for blood
pressure control and found to have a urinary tract infection;
for which she was treated times three days. The patient was
on beta blocker, 75 mg of metoprolol p.o. three times per day
for control of her blood pressure. An ACE inhibitor was
considered, but blood pressure then normalized, and the
patient was transferred from the Intensive Care Unit to the
floor for further management and disposition.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's blood
pressure four to five days prior to discharge averaged 130/80
with a heart rate between 80 and 90. The patient was
afebrile. On physical examination, the patient was awake and
alert. She spoke sporadically with sparse output. On
neurologic examination, the patient had a right gaze
deviation with a dense left hemiparesis of the arm greater
than the leg. The patient was not following tracking past
midline. She was able to withdrawal to pain on the left leg;
with slight grimacing. She did not withdraw or grimace with
pain in the left arm. The patient also had a facial droop on
the left side. On motor examination, the patient had
increased tone in the left greater than right bilaterally.
She also had a 4+/5 right hand grasp and biceps. On the left
side, she had [**1-6**] grasp with a positive drift. It was
difficult to assess motor in the lower extremities as the
patient could not hold up her legs bilaterally. On sensory
examination, the patient had normal light touch. Gait was
not tested. Coordination was slow on the left side.
HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was then
evaluated on the Neurology floor.
The patient was able to tolerate a diet with assistance after
video evaluation and swallow studies which the patient passed.
However, it was felt that she may not be able to feed herself in
adequate amounts. Therefore, the placement of a percutaneous
endoscopic gastrostomy tube was discussed with the family,
however, they declined.
The patient was then referred to a rehabilitation facility
for long-term placement and was approved prior to discharge.
The patient was on heparin 5000 units subcutaneously twice
per day for deep venous thrombosis prophylaxis with urine
cultures being negative since [**2100-6-14**]. The patient was
also started on atorvastatin for cardiovascular and stroke
prevention. Cholesterol was 196, high-density lipoprotein
was 31, and low-density lipoprotein was 94 which were drawn
on [**2100-6-15**].
Physical Therapy and Occupational Therapy assessed the
patient prior to discharge. The patient was to be discharged
on all inpatient medications on discharge.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE DIAGNOSIS: Right thalamic hemorrhagic stroke.
MEDICATIONS ON DISCHARGE: (Discharge medications were as
follows)
1. Senna one tablet p.o. twice per day.
2. Dulcolax 100 mg p.o. twice per day.
3. Ibuprofen 600 mg p.o. once per day.
4. Atorvastatin 20 mg p.o. once per day.
5. Metoprolol 75 mg p.o. three times per day.
6. Prevacid 30 mg p.o. every day.
7. Prednisone 5 mg p.o. once per day.
8. Regular insulin sliding-scale.
9. Heparin 5000 units subcutaneously q.12h.
DISCHARGE DISPOSITION: The patient was to be discharged to a
[**Hospital 4820**] rehabilitation facility (perhaps [**Hospital1 **]).
DR.[**Last Name (STitle) 726**],[**First Name3 (LF) 725**] 13-268
Dictated By:[**Name8 (MD) 15274**]
MEDQUIST36
D: [**2100-6-22**] 14:13
T: [**2100-6-22**] 14:31
JOB#: [**Job Number 15275**]
|
[
"5990",
"4019",
"2720"
] |
Admission Date: [**2106-10-14**] Discharge Date: [**2106-10-25**]
Date of Birth: [**2039-3-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
acute CHF exacerbation
Major Surgical or Invasive Procedure:
capsule endoscopy [**2106-10-20**]
History of Present Illness:
67M well known to our service, has PMH of EtOH cirrhosis
with HCC and is s/p OLT on [**8-17**] with ongoing issues of CHF
exacerbation and acute on chronic renal failure. He was recently
admitted to our service and was discharged on [**2106-9-28**] for CHF
exacerbation. His discharge summary and hospital course can be
found in OMR. Previously worked up on several admissions for GI
bleeding. EGD on [**3-22**] showing gastritis and varices.
For the past week, patient p/w acute onset dyspnea, weight gain,
weakness and edema. His symptoms were similar to that of his
recent hospitalization. He was admitted at [**Hospital3 **] hospital and
was treated for CHF exacerbation. However, patient developed
oliguria and required transfer to their ICU. He was started on
Lasix 200 IV BID and began to diurese abt 30-40ml/hr. His
respiratory status improved as he was weaned to nasal cannula
from BIPAP. Moreover, from their laboratory results, his Hct was
found to be 18, requiring 4 units pRBC. Per family's request,
patient is transferred to [**Hospital1 18**] for further management and care.
Otherwise, denies any fever, abdominal pain, N/V, hematochezia
or
hematemesis. Appropriate appetite. He did develop diarrhea and
required rectal tube placement.
Past Medical History:
liver transplant ([**2104-8-22**])
EtOH cirrhosis
HCC
anemia
essential thrombocytosis
prior complications of ascites
malnutrition
portal [**Month/Day/Year **] with grade 2 esophageal varices
h/o duodenitis [**7-18**]
grade 1 rectal varices
grade 2 esoph varices and gastritis by EGD [**3-/2106**]
CAD: ([**2104-7-1**] coronary angiography -inferolateral akinesis &
substantial lateral hypokinesis. 50% LAD lesion. Circ occluded
distally. RCA 40% stenosis)
CHF: ECHO [**9-19**], EF 25%
failure to thrive s/p PEG
Social History:
The patient owns business in [**Hospital3 **]: a clothing store and a
limousine business. Recently he started working from home due to
his poor health. He lives with his wife, who is very supportive.
He smokes. No drugs. Stopped EtOH in 6/[**2103**].
Family History:
Non contributory
Physical Exam:
weight baseline 44.1, now 49.5
Vitals: 97.8 74 134/71 20 97% 2L NC
Gen: NADS, cachetic, good spirited
Lungs: decreased bs to bases bilaterally, coarse
Cardio: RRR, 1+ SEM
Abd: soft, firm, incisions c/d/I, G tube in place, act BS, NT,
ND, G+
Ext: 2+ pedal edema, palpable pulses bilaterally
Neuo: no foal deficits elicited
Pertinent Results:
[**2106-10-14**] 10:13PM GLUCOSE-129* UREA N-89* CREAT-4.7* SODIUM-143
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-23 ANION GAP-19
[**2106-10-14**] 10:13PM ALT(SGPT)-8 AST(SGOT)-16 CK(CPK)-49 ALK
PHOS-51 TOT BILI-0.7
[**2106-10-14**] 10:13PM CK-MB-NotDone cTropnT-0.25*
[**2106-10-14**] 10:13PM CALCIUM-8.1* PHOSPHATE-7.0*# MAGNESIUM-2.1
[**2106-10-14**] 10:13PM WBC-7.3 RBC-3.70*# HGB-10.1*# HCT-30.8*#
MCV-83 MCH-27.2 MCHC-32.7 RDW-16.3*
[**2106-10-14**] 10:13PM PLT COUNT-417#
[**2106-10-14**] 10:13PM PT-13.1 PTT-34.0 INR(PT)-1.1
[**2106-10-14**]: CXR showed bilateral pleural effusions.
Brief Hospital Course:
The patient was admitted to the SICU on [**10-14**] with sudden onset
oliguria, acute CHF exacerbation, diarrhea and G+ stool.
Nephrology transplant, hepatology, gastroenterology, and
cardiology were consulted. Cardiac enzymes were followed and
trended downward. He was fluid restricted and diuresed. Daily
serum creatinine levels were 4.5-4.8. Initial hematocrit was
stable at 30.8 and trended upward with appropriate reticulocyte
count. Daily rapamycin levels were followed. On [**10-16**] he was
stable to be transferred to the floor. On [**10-20**] he underwent
capsule endoscopy to evaluate for midgut GI bleed and results
were pending. He also received IV iron on [**10-21**], but towards the
end of this infusion (500mg/500cc), he became acutely short of
breath after ambulating to the bathroom off O2. O2 dropped to
low 80s. He was hypertensive and tachypneic. A non-rebreather
was applied with improved O2 to 90-91%. IV lasix and iv
lopressor were given with slight improvement. CXR showed severe
symmetric bilateral opacification worse in the lower lungs had
progressed, particularly on the left, accompanied by stable
moderate left and small right pleural effusion. EKG was stable.
Levaquin was started for pneumonia. He was transferred to the
SICU for management. He was briefly placed on bipap and was
subsequently weaned to a non-rebreather after more iv lasix and
IV hydralzine were given. A lasix drip was started. O2 sats
improved and the non-rebreather was switched to nasal cannula.
The lasix drip was changed to po lasix. He was transferred out
of the SICU.
Nephrology discussed potential need for hemodialysis in the
future. Vein mapping was recommended. This was done on [**10-25**].
He was discharged to home with home O2 as he desaturated to 87%
while ambulating. Vital signs were stable.
Of note, rapamune dose was adjusted for trough level of 10 on
[**10-24**]. Dose was decreased to 2.5mg qd. A script for liquid
rapamune was provided. Levaquin course was completed as of [**10-25**].
Medications on Admission:
Meds from [**Hospital3 **]: epo, coreg 12.5'', iron, pancrease, rapamune
3 tabs daily, lasix 200 IV'', nitropaste, testosterone patch,
pepcid 20, prednisone 5, remeron 15, sodium bicarb 1300''', tums
1000''', zocor 10
Discharge Medications:
1. Coreg 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
2. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
3. Epoetin Alfa 40,000 unit/mL Solution Sig: One (1) mL
Injection once a week.
4. Rapamune 1 mg Tablet Sig: 2.5 Tablets PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
5. Lasix 40 mg Tablet Sig: Three (3) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*2*
6. Nitro-[**Hospital1 **] 2 % Ointment Sig: Take as directed. Transdermal as
directed.
7. Testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24
hr Transdermal DAILY (Daily).
8. Pepcid 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
Disp:*180 Tablet, Chewable(s)* Refills:*2*
12. Zocor 10 mg Tablet Sig: One (1) Tablet PO once a day.
13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO three times a day.
14. Colace 50 mg/5 mL Liquid Sig: Five (5) mL PO twice a day.
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO once a day.
16. Home Oxygen
Please provide home Oxygen 2 liters nasal canula continuous
Patient desats to 87% on room air
17. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Rapamune 1 mg/mL Solution Sig: 2.5 ml PO once a day.
Disp:*60 bottle* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Oliguria
Acute CHF exacerbation
Anemia with occult GI bleed
acute on chronic renal failure
pneumonia
Discharge Condition:
Hemodynamically stable, tolerating regular diet, and pain under
adequate control.
Discharge Instructions:
You were transferred to the [**Hospital1 18**] transplant surgery service for
continued management of low urine output, acute CHF
exacerbation, anemia with detected blood in stool. You received
blood transfusions at [**Hospital3 **] Hospital, but since transfer to
[**Hospital1 18**], your hematocrit was stable at 30 and continued to improve
to 34-36. You were kept on a fluid-restricted diet and
administered diuretic medications to control your CHF.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight change > 3 lbs.
Adhere to 2 gm sodium diet.
Fluid Restriction: 1.5 L daily.
Please call your doctor or go to the emergency room if you
develop fever, chills, nausea, vomiting, bloody vomit or stools,
chest pain, difficulty breathing, or any other concerning
symptom.
Followup Instructions:
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2106-10-22**]
8:30
Please call ([**Telephone/Fax (1) 3618**] to schedule a follow-up appointment
with Dr. [**Last Name (STitle) **] in [**2-12**] weeks.
Please follow up with your nephrologist in [**2-12**] weeks.
Please call ([**Telephone/Fax (1) 2306**] in 1 week to obtain the results of
your capsule endoscopy from Dr. [**Last Name (STitle) **] and follow up
accordingly.
Completed by:[**2106-10-25**]
|
[
"5849",
"486",
"4280",
"41401",
"3051"
] |
Admission Date: [**2149-9-26**] Discharge Date: [**2149-9-29**]
Service: MEDICINE
Allergies:
Ibuprofen
Attending:[**First Name3 (LF) 2610**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo female with history of TB sp treatment, bronchiectasis,
untreated MAC (diagnosed [**6-/2149**]), atrial fibrillation who
presents with worsening shortness of breath. Patient was
hospitalized in [**6-/2149**] with hemoptysis and shortness of breath.
At that time she was diagnosed with pneumonia/bronchiectasis and
treated with ceftriaxone/azithromycin with improvment in
symptoms. After discharge sputum samples revealed MAC. She
underwent no treatment of MAC given her frail state and the
feeling that she would not live through treatment. Since the
last DC she has been on home 02.
.
Patient states the last several weeks her breathing has become
progressively worse. She saw her PCP the day prior to admission
and declined hospital admission at that time. Today she felt her
breathing was worse with ambulation and agreed to evaluation at
the hospital. Denies fever, chills, chest pain, productive
cough. Denies lower extremity edema, orthopnea, PND.
.
Initial VS in the ED: 97.9 99 152/89 18 95%. Labs revealed a
normocytic anemia with hematocrit of 28.1 which is down from 32
in [**6-/2149**], INR 3.5, Lactate of 1.4, UA with 31 WBC and few
bacteria, nitrite negative. CXR with bilateral lower lobe
effusion with possible peripneumonic effusions. Patient was
given Vancomycin and Levofloxacin. EKG with A. Fib. VS prior to
transfer: 98.9 87 AF 150/74 25 99% 3L.
.
On the floor, feels fine, comfortable.
Past Medical History:
- Paroxysmal atrial fibrillation
- History of pulmonary tuberculosis
--->treated with pneumothoraces and subsequently with PAS/INH 50
years ago
--->PFTs [**2144**]: FEV1 0.86, FEV1/FVC 128% predicted. DLSO not
performed
--->prior CT revealing for calcified granulomas in the right
lower lobe and left lower lobe, calcified pleural scar on the
right, and fibrotic changes in the right lower lobe leading to a
mediastinal shift to the right
- MGUS
- Osteoporosis
- Cervical Osteoarthritis
- s/p cataract extraction
Social History:
The patient is currently a resident at [**Location (un) 5481**] independent
living. She has two children, who do not live in the area. She
was previously employed as a dental hygienist. She is
independent in her ADL's. She denies tobacco or EtOH use.
Family History:
Mother: Died age 80 [**2-12**] MI
Father: Died in 80s [**2-12**] MI
No family history of lung cancer or other lung disease.
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.9 BP: 133/63 P: 63 R: 18 O2: 97 3L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: decrease BS bilateral bases, with fine rales, occasional
wheeze right lower lung fields, no egophony, minimal dullness to
percussion along the lower lung fields, no accessory muscle use
CV: Irregular, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis, left
lower extremity with trace edema (patient notes this to be
chronic.
Discharge Physical Exam:
Pertinent Results:
Admission Labs:
[**2149-9-26**] 11:55AM BLOOD WBC-6.5 RBC-3.24* Hgb-9.0* Hct-28.1*
MCV-87# MCH-27.9 MCHC-32.1 RDW-15.8* Plt Ct-317
[**2149-9-26**] 11:55AM BLOOD PT-35.0* PTT-27.1 INR(PT)-3.5*
[**2149-9-26**] 11:55AM BLOOD Glucose-104* UreaN-19 Creat-0.6 Na-143
K-3.8 Cl-102 HCO3-34* AnGap-11
[**2149-9-26**] 12:04PM BLOOD Lactate-1.4
Discharge Labs:
Studies:
CXR ([**2149-9-26**]): IMPRESSION: 1. Moderate pulmonary edema. 2.
Increased size of moderate right and small left pleural
effusions. 3. Bibasilar airspace opacities which could reflect
atelectasis though infection or aspiration cannot be excluded.
4. Large hiatal hernia.
Brief Hospital Course:
[**Age over 90 **] yo female with history of TB s/p treatment, bronchiectasis,
untreated MAC (diagnosed [**6-/2149**]), atrial fibrillation who
presented with worsening shortness of breath, CXR concerning for
bilateral lower lobe opacification with possible peripneumonic
effusion.
.
Active issues:
.
#SOB/Cough: Upon admission, the patient described an increasing
oxygen requirement for the past few days without fever, and with
no evidence of leukocytosis. At that time, she demonstrated no
signs of volume overload and her CXR was thought to be due to
untreated MAC infection. However, overnight, she desaturated
down to the low 80%, required 10L on a non-rebreather to
maintain her oxygen saturation, and was thought to be volume
overloaded with evidence of pulmonary edema on her subsequent
CXR. She was subsequently transferred to the MICU for BIPAP
given her worsening oxygen requirement. In the ICU the family
decided to make the patient CMO wo continuation of lasix, abx,
or other non-comfort medications (inhalers, bowel regimen, and
beta blocker continued). Her geriatrician from the NH arranged
for dispo back to the NH with hospice services under new code
status on [**2149-9-29**].
.
# Pyuria: No symptoms. Lots of epis on UA. No antibiotics given
current goals of care.
.
# Atrial Fibrillation: Rate Controlled. Continued metoprolol for
comfort.
.
# Normocytic Anemia: HCT down from 32 to 28. No evidence of
acute bleed. Labs discontinued.
.
#. Depression: Continue Mirtazapine for sleep assistance.
.
Pt will be discharged to hospice services. Palliative care
consult initiated at [**Hospital1 18**] w/ follow-up to be managed by hospice
at outpatient facility.
Medications on Admission:
- Calcium Carbonate 200mg PO three times a day
- Omeprazole 20mg PO daily
- conjugated estrogens 0.3 mg Daily
- multivitamin one tab daily
- donepezil 5 mg Tablet QHS
- mirtazapine 45 mg daily
- fluticasone-salmeterol 250-50 mcg/dose one inhalation daily
- B complex vitamins one daily
- cholecalciferol (vitamin D3) 1,000 unit daily
- atorvastatin 10 mg Tablet Sig: 0.5 tablet daily
- metoprolol tartrate 25 mg Tablet [**Hospital1 **]
- warfarin 3mg Daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
2. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever, pain.
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. mirtazapine 30 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime).
6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation Q6H (every 6 hours) as
needed for shortness of breath or wheezing.
7. ipratropium bromide 0.02 % Solution Sig: One (1) ml
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. morphine 15 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*25 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 5481**] TCU
Discharge Diagnosis:
Pulmonary edema
Atrial fibrillation
MAC - untreated
Discharge Condition:
Mental Status: Confused - sometimes.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 **].
You were admitted with shortness of breath related to fluid in
your lung and your heart arrhythmia (atrial fibrillation). A
meeting was held with you and your family to determine the most
appropriate management for you given your recently declining
health and wish to prioritize quality of life. Plans were made
to transition you to hospice at your current nursing home with
an emphasis on comfort care.
The following changes were made to your medications:
STOPPED all non-comfort medications
Continued: inhalers, betablocker, bowel regimen, sleep aids
STARTED morphine orally as needed for dyspnea and pain
You have several follow-up appointments with [**Hospital1 18**] physicians.
These appointments have been detailed in the follow-up section
below.
Should you desire medical evaluation in the future, please call
your primary care physician to make an appointment, or if you
need more immediate attention seek care at the emergency
department.
Followup Instructions:
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2149-10-1**] at 12:40 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2149-10-1**] at 1 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PFT
When: WEDNESDAY [**2149-10-1**] at 1 PM
Completed by:[**2149-10-2**]
|
[
"42731",
"4280",
"53081"
] |
Admission Date: [**2180-1-12**] Discharge Date: [**2180-1-15**]
Date of Birth: [**2121-6-11**] Sex: M
Service: MEDICINE
Allergies:
Reglan / heparin (porcine) / Vancomycin
Attending:[**First Name3 (LF) 20146**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
This is a 58 year old gentleman with a complicated past medical
history notable for diverticulosis s/p perforated diverticulum
in [**2175**] necessitating anterior resection with descending
colostomy with hospital course complicated by multiorgan
failure, ongoing colitis attributed to ulcerative vs.
diverticular associated colitis of both proximal and distal
areas to the stoma, ongoing colostomy bleeding, peristomal
varices, who presents today with bright red blood per stoma bag.
Patient reports large volume bright red blood from his stoma
starting at 11PM last evening. Overnight and over the course of
the day, he has filled his bag completely six times with bright
red blood. He reported dizziness, shortness of breath, and
shoulder discomfort/heaviness, for 20 minutes which resolved
with fluids. Denies any abdominal pain, nausea, vomiting,
fevers, chills. No NSAIDs or alcohol consumption for several
months.
Of note, patient sees Dr. [**Last Name (STitle) 3708**] and Dr. [**Last Name (STitle) 10446**] of GI, and is
noted to be of poor medication compliance. He has been tried on
oral asacol with canasa supposotories.
In the ED, initial vital signs were: 98.4, HR: 103, BP: 70/30,
RR: 16, 99%RA. 2 large bore IVs were placed and patient was
volume resuscitated with 4L NS and transfused with 2 unit prbcs.
Patient was started on protonix gtt. Blood pressure improved
to 94/72 with improvement in tachycardia. ECG with no signs of
ischemia. Labs notable for a hematocrit of 31.9 (baseline),
creatinine of 1.8 (1.9 in [**11/2179**]), and a lactate of 2.7.
Initial cardiac enzymes negative times one. CXR without acute
process. GI was consulted who recommended IV PPI, trending hct,
possible colonoscopy. Surgery was consulted who believed
bleeding to be IBD or diverticular. Vitals at the time of
transfer: HR: 70, BP: 94/72, RR: 13, 100%RA.
Past Medical History:
1. Diverticulosis with diverticular perforation in [**2175**]
2. Descending colostomy.
3. Bleeding from site of stoma.
4. Persistent rectal bleeding and ongoing colitis attributed to
ulcerative vs. diverticular associated colitis
5. Diabetes Mellitus II
6. ?para stomal varices related to PVT
7. Stricture at stomal insertion site
8. Chronic kidney disease subsequent to multiorgan failure at
the time of his [**2175**] admission, with baseline creatinine 1.6
9. Attention deficit hyperactivity disorder
Social History:
Chronic kidney disease subsequent to multiorgan failure at the
time of his [**2175**] admission, with baseline creatinine 1.6 in
06/[**2177**]. Patient is not married, not sexually active for the
past five years. Cigarettes - denies. Alcohol - denies, illicit
drugs - denies.
Family History:
Throat cancer in his father. DM in his family.
Physical Exam:
VS: Temp: 96.6, BP: 114/69, HR: 79, RR: 9, O2sat: 100% RA
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, dry mucous membranes, op without
lesions, no supraclavicular or cervical lymphadenopathy, no jvd,
no carotid bruits, no thyromegaly or thyroid nodules
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: left sided ostomy /s, soft, nt, no masses or
hepatosplenomegaly
EXT: no pedal edema
SKIN: no rashes/no jaundice/no splinters
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
Pertinent Results:
Admission labs:
[**2180-1-12**] 04:15PM GLUCOSE-214* UREA N-37* CREAT-1.8* SODIUM-136
POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-17* ANION GAP-16
[**2180-1-12**] 04:15PM ALT(SGPT)-32 AST(SGOT)-27 ALK PHOS-84 TOT
BILI-0.5
[**2180-1-12**] 04:15PM LIPASE-36
[**2180-1-12**] 04:15PM cTropnT-<0.01
[**2180-1-12**] 04:15PM PHOSPHATE-3.5 MAGNESIUM-1.8
[**2180-1-12**] 04:15PM WBC-11.0# RBC-3.87* HGB-11.0* HCT-31.9*
MCV-83 MCH-28.5 MCHC-34.5 RDW-15.2
[**2180-1-12**] 04:15PM NEUTS-81.1* LYMPHS-13.0* MONOS-4.2 EOS-1.5
BASOS-0.3
[**2180-1-12**] 04:15PM PLT COUNT-118*
[**2180-1-12**] 04:15PM PT-15.2* PTT-31.5 INR(PT)-1.3*
[**2180-1-12**] 11:44PM CK(CPK)-46*
[**2180-1-12**] 11:44PM CK-MB-2 cTropnT-<0.01
[**2180-1-12**] 04:44PM LACTATE-2.7* K+-5.0
EKG: Normal sinus rhythm with rate of 76, left axis deviation,
no ST or T wave changes concerning for ischemia. Unchanged from
prior ECG in [**2179-11-8**].
Imaging:
.
# Endoscopy:
[**6-14**] colonoscopy: Petechiae and congestion in the whole colon
compatible with ischemia (biopsy). Polyp in the transverse
colon (polypectomy).
.
[**1-18**] colonoscopy: Erythema, nodularity in the colon compatible
with mild colitis (biopsy). Erythema, congestion, friability
nodularity with polyps suggestive of inflammatory polyps seen in
the distal 20 cm to stoma. Friability limited ability to take
biopsies at this site given thrombocytopenia and risk of
bleeding in the colon. Otherwise normal colonoscopy to terminal
ileum
Chest Radiograph [**2179-1-12**]: No acute process.
Brief Hospital Course:
This is a 58 year old gentleman with a complicated past medical
history notable for diverticulosis c/b perforated diverticulum
in [**2175**] s/p anterior resection with descending colostomy,
ongoing colitis (ulcerative vs. diverticular), ongoing colostomy
bleeding, peristomal varices, who presented with bright red
blood per stoma bag, evidence of ulcerative colitis on
colonoscopy.
# GI Bleed: Based on history of prior parastomal varices,
diverticulosis, bleeding from significant colitis in combination
with appearance of bright red blood per stoma, most likely
source of bleeding was lower GI source. Patient refused NG
lavage in the ED. He was transfused 4 units total PRBC and
received IVF, was then HDS and with brown stools. Surgery and IR
were consulted, no need for intervention, GI recommended
colonoscopy and IV PPI [**Hospital1 **]. Colonoscopy without complications,
patient found to have inflammatory changes and polyps around
stoma site. Biopsies taken, patient to follow with PCP and
gastroenterologist Dr. [**Last Name (STitle) 3708**]. Patient has been informed of
preliminary colonsocopy findings, has been advised to continue
mesalamine PO and suppositories, and home iron supplements. He
has a history of nonadherence to medications and importance of
medication compliance was discussed at length with patient.
# Hypotension: Likely was hypovolemic in ICU in the setting of
ongoing gastrointestinal bleeding. Status post 3L NS with
appropriate response in blood pressure. However, patient with
elevated lactate and relative leukocytosis and must therefore
rule out any potential causes of sepsis. Blood cultures were
sent and are pending. CXR was clear. UA was ordered, found to
have large amounts WBCs, few bacteria. UA discussed below.
Lactate trended down to normal with IVF and PRBC. Home
lisinopril and tamsulosin were held during admission and
restarted in discharge, as BPs were stable.
# Acute on chronic Anemia: Hematocrit currently at baseline on
admission, but dropped with IVF/volume resusication versus
ongoing bleeding (although no further blood in his bag). Has
known iron deficiency anemia. He was given 2 units PRBC in the
ED and another unit the am of [**1-13**]. Serial hematocrits were
checked, hct stable. Patient advised to continue home iron
supplements at discharge.
# CP: Had one episode of CP in ICU, may have been secondary
demand ischemia in setting of anemia and acute blood loss.
Patient's description of pain as bilateral shoulder cramping
suggests tissue ischemia, lactate build-up. ECG without
ischemic signs and cardiac enzymes negative time three. No
further episodes of CP during admission
# Thrombocytopenia and leukopenia: Patinet with baseline Plts of
about 80, WBC 4.9. Was higher on admission (likely
hemoconcentrated). Dropped overnight with resuscitation to 40
and 2.7, respectively, unusual lows for pt. Chronic
thrombocytopenia thought to be secondary to splenic
sequestration, enlarged spleen on prior CT. Peripheral smear
sent, no schistocytes, platelet clumping, or evidence of
peripheral blood heme malignancy. Given pt's leukopenia, was
tested for HIV, which was negative. Would consider rechecking
CBC at f/u visit, and if not improving, would consider bone
marrow biopsy in future if counts do not increase.
#Dysuria: UA with elevated WBC, few bacteria, rechecked and
showed >800 WBC also with few bacteria. Pt complained of
dysuria now much like in the recent past, he was recently
treated with 2 week course of cipro with no improvement. UA was
rechecked, initial urine cx grew mixed colonies (likely
contaminated), second ucx was negative. Initially was treated
with cipro, was dc'ed when second cx negative. Rectal exam was
done to eval for prostatitis, no prostate tenderness. He did
complain of penile discharge in the last few days, however no
recent sexual contacts, but a GC/chlamydia urine PCR was sent,
results pending on discharge. Would consider repeat UA after
discharge to ensure pyuria resolved.
# Chronic kidney disease: Secondary to multiorgan failure at the
time of prior [**2175**] admission. Creatinine at baseline on
admission.
# Diabetes: Home glipizide was held while not on a regular diet.
He was covered with a sliding scale, will continue home
medications on discharge.
Code: Full
Issues on discharge:
-Would recheck CBC at f/u appointment to trend WBC, was
leukopenic during admission, HIV negative
-Would recheck UA to ensure resolution of pyuria
-GC/chlamydia urine PCR pending (sent to evaluate penile
discharge)
Medications on Admission:
- gabapentin 600mg PO TID
- glipizide 5mg PO daily
- lisinopril 10mg PO daily
- tamsulosin 0.4mg PO daily
- ferrous gluconate 324mg PO daily
- patient is written for mesalamine 1200mg PO BID but does NOT
take this medication
- patient is written for mesalamine 1000mg suppository rectally
once a day but does NOT take this medication
Discharge Medications:
1. ferrous gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime) for 1 doses.
3. mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*180 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. gabapentin 600 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
5. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet
Extended Rel 24 hr PO once a day.
6. mesalamine 1,000 mg Suppository Sig: One (1) Rectal QPM
(once a day (in the evening)).
Disp:*30 suppository* Refills:*2*
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal bleed
Colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were seen in the hospital for blood coming out of your
stoma, which resolved on its own. This was most likely due to
polyps found in your colon near your stoma site during
colonoscopy. The colonoscopy showed that these polyps might be
signs of inflammation. Some of these polyps were sampled during
the colonoscopy to better understand the type of inflammation.
To counter the inflammation, you should start taking mesalamine
twice a day and also canasa suppositories in your rectum every
evening. If you feel the medications don't work well for you,
you should inform your gastroenterologist Dr. [**Last Name (STitle) 3708**].
You were also found to have a urinary tract infection. Please
continue taking ciprofloxacin for the next 2 weeks (last day
[**1-27**])
Changes to your medications:
-START taking ciprofloxacin twice a day for the next 12 days
(last day [**1-27**])
-CONTINUE taking mesalamine 1200 mg [**Hospital1 **] and canasa suppository
every night
Followup Instructions:
Please make an appointment with Dr. [**Last Name (STitle) **] in [**1-9**] weeks, at
([**Telephone/Fax (1) 1300**] in order to follow up and discuss your
medications
Please also make an appointment with your gastroenterologist,
Dr. [**Last Name (STitle) 3708**]. At this appointment you will discuss the results of
your biopsy, and further diagnosis and treatment options. The
phone number is [**Telephone/Fax (1) 65629**]. Please make an appointment in
about 2 weeks.
Completed by:[**2180-1-16**]
|
[
"2851",
"2875",
"25000",
"5859"
] |
Admission Date: [**2180-12-23**] Discharge Date: [**2180-12-27**]
Service: TRAUMA SURGERY
BRIEF HOSPITAL COURSE: This 82-year-old gentleman was
transferred on [**2180-12-23**] from [**Hospital 8**] Hospital,
where he was originally worked up after being found by EMS
pinned between his car and garage door. After being released
by Emergency Medical Services, he was reportedly
hemodynamically stable in the field, but complaining of left
hip pain and left leg pain. He was alert and oriented with [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 2611**] coma score of 15 at the scene.
Workup at [**Hospital 8**] Hospital revealed bilateral pubic rami
fractures and the patient was transferred to the [**Hospital1 **] Hospital after he developed abdominal pain and
tenderness and a drop in his hematocrit of 10 points.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Benign prostatic hypertrophy.
3. Depression.
4. Inguinal hernia.
5. Gastritis.
6. Herniated disk.
7. Hyperplastic polyps by colonoscopy.
PAST SURGICAL HISTORY: Back surgery and laparoscopic
cholecystectomy.
MEDICATIONS:
1. Zoloft.
2. Hydrochlorothiazide.
3. Hytrin.
4. Prilosec.
5. Detrol.
SOCIAL HISTORY: No tobacco use.
PHYSICAL EXAMINATION: Upon arrival at the [**Hospital1 **] Hospital, the patient's temperature was 97.8, heart
rate was 107, blood pressure is 157/82, and he was saturating
98% on room air. In terms of his physical exam, he was
normocephalic, atraumatic with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2611**] coma score of 13 due
to the fact that he was somewhat confused and agitated. He
was however, moving his extremities spontaneously and opening
his eyes spontaneously. Neurologic examination showed no
focal deficit with a cervical collar in place. Chest
examination revealed clear lungs. Cardiac examination showed
regular, rate, and rhythm with an audible S1, S2. Abdominal
examination showed a soft-nontender abdomen, and rectal
examination showed good tone and was heme negative.
Extremity examination revealed a left flank ecchymosis and an
abrasion at the left knee and right shin, and a small
abrasion also on the left hip. FAST examination was
negative.
Radiographic workup for this patient at the [**Hospital1 **] Hospital revealed no acute bleed or acute process
by head CT scan. No fracture or dislocation by neck CT scan
with reconstruction.
Pelvis CT scan showed a left ischial fracture, a right sacral
fracture, a partial right sacroiliac joint fracture that was
mildly displaced. A right ischial fracture with a slight
depression, a right medial acetabular fracture which was
nondisplaced, but intra-articular, and a left superior ramus
fracture.
Abdominal CT scan was negative for free air or free fluid,
but did reveal a small amount of atelectasis in the lower
lung lobes bilaterally. CT scan also revealed two liver
lesions that were morphologically consistent with cysts.
Admission laboratories included a white count of 14,
hematocrit of 32, and a platelet count of 218. Coagulation
factors were within normal limits as were initial
chemistries. A tox screen was negative and the patient was
found to have gross hematuria.
The admission plan for this patient included admission to the
Trauma SICU as the patient required intubation in light of
his substantial confusion and agitation at time of transfer.
The plan also included serial hematocrits that were to be
checked to exclude the possibility of continued abdominal or
pelvic bleed.
Orthopedics was consulted as part of the patient's initial
workup. After discussion with Dr. [**First Name (STitle) 1022**], attending on the
Orthopedic service, it was his recommendation that all of the
pubic and sacroiliac fractures found on this patient were
suitable for nonoperative management.
On hospital day two, the patient continued to be intubated in
the Trauma Intensive Care Unit. His vital signs were stable
and he was afebrile throughout the day. On hospital day
three, the patient was extubated and once again expressed
some concern about pain in his left flank. On serial
examinations this pain appeared to be diminishing, and was
clearly less severe than at the time of the patient's
admission.
On hospital day four, as the patient's condition continued to
be stable, and his hematocrit was also stable, the patient
was transferred to the floor. His diet was advanced to adlib
and his Foley was discontinued. After reaching the floor,
the patient was evaluated by physical therapy, whose clinical
impression was that this patient would require short-term
assistance at rehabilitation prior to him returning to home
due to his difficulty with mobility secondary to his pelvic
fractures. His rehabilitation potential was considered good.
On hospital day five, the patient's hematocrit was once again
checked, and was stable. He continued to work with physical
therapy and tolerate a regular diet. His condition was
appropriate for discharge to a rehabilitation center, as he
had been accepted by a rehabilitation center, and a bed was
available.
The patient was discharged to an appropriate rehabilitation
facility.
DISCHARGE STATUS: Approved.
CONDITION ON DISCHARGE: Good.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern1) 13717**]
MEDQUIST36
D: [**2180-12-27**] 09:58
T: [**2180-12-27**] 09:57
JOB#: [**Job Number 41178**]
|
[
"4019",
"311"
] |
Admission Date: [**2158-11-3**] Discharge Date: [**2158-11-12**]
Date of Birth: [**2113-1-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain; transfer from OSH for cardiac cath, left main
disease, awaiting CABG
Major Surgical or Invasive Procedure:
Cardiac Catheterization
[**2158-11-7**] Coronary artery bypass graft x3, LIMA to LAD,
reverse saphenous vein graft to diagonal and
reverse saphenous vein graft to the PLV
History of Present Illness:
45 year old man referred from [**Hospital6 3622**] for unstable angina. He is an active smoker,
diabetic, hypertension, hyperlipidemia, and a family history of
premature CAD. He had resting pain yesterday, ruled out for MI
with 3 sets of enzymes, no EKG changes. Cath shows an ulcerated
proximal LAD lesion with distal LAD disease, tight D1 (both
relatively small vessels) and a diffusely diseased RCA with
patent R-PDA and RLV branches. He was then referred for surgical
revascularization.
Past Medical History:
Hypertension
Hyperlipidemia
Diabetes Mellitus
Social History:
-Tobacco history: Smokes currently. 25 pack year history.
-ETOH: denies
-Illicit drugs: denies
Lives with: Wife
Occupation: unemployed
Family History:
Father had CABG at 60. Mother had [**Name (NI) 2320**].
Physical Exam:
VS: T=97 BP=101/68 HR=67 RR=16 O2 sat=100RA
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 7 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, with a split S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
[**2158-11-3**] 05:22PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2158-11-3**] 05:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
[**2158-11-3**] 01:50PM GLUCOSE-156* UREA N-14 CREAT-0.9 SODIUM-134
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-25 ANION GAP-11
[**2158-11-3**] 01:50PM estGFR-Using this
[**2158-11-3**] 01:50PM ALT(SGPT)-18 AST(SGOT)-17 ALK PHOS-66
AMYLASE-55 TOT BILI-0.6
[**2158-11-3**] 01:50PM ALBUMIN-4.0 CALCIUM-8.8
[**2158-11-3**] 01:50PM VIT B12-252
[**2158-11-3**] 01:50PM %HbA1c-7.9* eAG-180*
[**2158-11-3**] 01:50PM WBC-10.2 RBC-4.11* HGB-11.9* HCT-34.5* MCV-84
MCH-29.0 MCHC-34.7 RDW-14.7
[**2158-11-3**] 01:50PM PLT COUNT-201
[**2158-11-3**] 01:50PM PT-14.9* PTT-150* INR(PT)-1.3*
CXR [**2158-11-3**]:FINDINGS: Frontal and lateral views of the chest
are obtained. Lungs are
clear without focal consolidation. No pleural effusion or
pneumothorax is
seen. The cardiac and mediastinal silhouettes are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
TTE [**2158-11-3**]:The left atrium is normal in size. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF 65%). Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
Carotid Dopplers [**2158-11-3**]: Impression: Right ICA 0 stenosis.
Left ICA <40% stenosis.
Intra-op TEE [**2158-11-7**]
PRE-CPB:1. The left atrium is normal in size. No spontaneous
echo contrast is seen in the left atrial appendage. The left
atrial appendage emptying velocity is depressed (<0.2m/s). No
thrombus is seen in the left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. Left ventricular wall thicknesses and cavity size are normal.
4. Right ventricular chamber size and free wall motion are
normal.
5. The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque.
6. There are simple atheroma in the descending thoracic aorta.
7. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen.
8. Trivial mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results.
P)[**Last Name (un) **]-CPB: On infusion of phenylephrine. AV pacing, then
apacing. Preserved biventricular systolic function. Trace MR,
TR. Aortic contour is normal post decannulation.
Brief Hospital Course:
Mr. [**Known lastname **] is a 45 year old man with a history of type 2
diabetes, current tobacco abuse, hyperlipidemia and strong
family history of premature CAD, who was admitted to [**Hospital3 **] on [**2158-11-2**] complaining of chest pain at rest and
diagnosed with ACS/unstable angina. Cardiac cath at [**Hospital1 18**] showed
severe LAD and RCA disease. After the routine preoperative
work-up, the patient was taken to the operating room on [**2158-11-7**]
where the patient underwent CABG x 3 as detailed in Dr.[**Name (NI) 11272**]
operative report. Overall the patient tolerated the procedure
well and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable, weaned from inotropic and vasopressor support. Beta
blocker was initiated and the patient was gently diuresed toward
the preoperative weight. Toradol was added to analgesic
regimen. He did develop a fever of 101degF and urine culture
was negative. The patient remained in the CVICU for an extra
night due to bed shortage on telemetry floor. [**Last Name (un) **] was
consulted for assistance with diabetes management. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility.
By the time of discharge on POD #5 the patient was ambulating
freely, the wound was healing and pain was controlled with oral
analgesics. The patient was discharged to home in good
condition with appropriate follow up instructions. The cardaic
surgery office will call with follow up appointments with Dr.
[**First Name (STitle) **] and a cardiology appointment will be arranged for you.
Medications on Admission:
home medications:
lisinopril 20mg daily
zocor 20mg daily
metformin 1000mg [**Hospital1 **]
actos 5mg daily
glipizide 10mg [**Hospital1 **]
aspirin 81mg daily
previously on avandia
.
medications on transfer:
morphine prn
nitro prn
aspirin 325mg daily givenn [**11-3**] at 0940
heparin gtt
insulin glargine 8 units qhs
insulin humalog SS
lisinopril 20mg daily
metoprolol 12.5mg [**Hospital1 **]
simvastatin 80mg qhs
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain: prn pain.
Disp:*65 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Lantus 100 unit/mL Solution Sig: Twenty Six (26) units
Subcutaneous at bedtime.
Disp:*1 vial* Refills:*2*
7. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous three
times a day: per sliding scale.
Disp:*1 Humalog (Subcutaneous) 100 unit/mL Solution* Refills:*2*
8. insulin syringes (disposable) 1 mL Syringe Sig: One Hundred
Fifty (150) Miscellaneous four times a day.
Disp:*150 1 mL Syringe* Refills:*2*
9. insulin syringe-needle,dispos. 1 mL 28 x [**12-10**] Syringe Sig:
One [**Age over 90 1230**]y (150) Miscellaneous four times a day.
Disp:*150 1 mL 28 x [**12-10**] Syringe* Refills:*2*
10. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. Humalog Pen 100 unit/mL Insulin Pen Sig: as directed by
sliding scale units Subcutaneous four times a day: based on pre-
meal and bedtime fingerstick.
Disp:*1 pen* Refills:*2*
13. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1)
Inhalation twice a day.
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
Disp:*7 Tablet(s)* Refills:*0*
15. potassium chloride 10 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Severe two vessel coronary artery disease
Unstable Angina/Acute Coronary Syndrome
Hypertension
Hyperlipidemia
Diabetes Mellitus
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Leg incison: healing well, no erythema or drainage
Edema: +1 bilat lower extremities
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Leg incison: healing well, no erythema or drainage
Edema: +1 bilat lower extremities
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Leg incison: healing well, no erythema or drainage
Edema: +1 bilat lower extremities
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
The cardiac surgery office [**Telephone/Fax (1) 170**] will contact you with
the following appointments:
Surgeon Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**]
A Cardiology appointment will be made for you as well.
Please call to schedule the following:
Primary Care Dr. [**First Name (STitle) **],[**First Name3 (LF) **] H. [**Telephone/Fax (1) 79281**] in [**3-13**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2158-11-12**]
|
[
"41401",
"25000",
"2724",
"2859",
"4019",
"3051"
] |
Admission Date: [**2124-3-29**] Discharge Date: [**2124-4-8**]
Date of Birth: [**2063-8-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Syncope.
Major Surgical or Invasive Procedure:
Percutaneous transvenous clot extraction from pulmonary artery.
Removal of internal cardioverter difibrillator.
Removal of PICC line with placement of Swan-Ganz catheter to
prevent further pulmonary embolism.
New PICC line placement because nafcillin cannot be used by
midline.
History of Present Illness:
Mr. [**Known lastname **] is a 60-year-old man with dilated non-ischemic
cardiomyopathy (clean cath.; LVEF 15%), with ICD placement and
removal after complication by MSSA endocarditis, undergoing
antibiotic therapy at rehabilitation, presenting to [**Hospital1 18**] after
a syncopal episode.
Mr. [**Known lastname **] has been at [**Hospital3 **] for about one week,
where he has been receiving oxacillin for his endocarditis. Just
after lunch today, Mr. [**Known lastname **] was watching television with
family when his 'eyes rolled back in his head' and he lost
consciousness. Staff described him as [**Doctor Last Name 352**] with agonal breathing
and pinpoint pupils. He was placed on a non-rebreather. Blood
sugar was 111. Tele strips at the time demonstrate AFib with HR
about 38. Documentation of the event varies. [**Name6 (MD) **] the MD note, he
regained consciousness and was coherent within 60 seconds. Per
the nursing staff, he gained awareness within 10 minutes but
could not recall what had happened. BP immediately after event
was 80/40 with pulse 70-90. He was given 500cc NS bolus and a
dose of 2g IV cefepime.
Upon arrival to the ED, initial vitals were 98.0 101/67 100 18
100% NRB. He was given flagyl 500mg IV and zosyn 4.5g IV. He
became hypotensive to 88/61 and received 1L of IVF and was
started on a levophed gtt. A left groin CVL was placed. Work-up
revealed a right central PE with concern for wedge infarct.
Given that his INR was elevated at 5, he was not considered a
candidate for thrombolysis. He was therefore transferred to the
cath lab for possible thrombectomy.
In the cath lab, a right heart cath showed pulmonary HTN and
pulmonary angiogram was done, demonstrating embolic occlusion of
subsegmental branch in the right middle lobe. A thrombectomy was
performed with restoration of blood flow. The team then placed a
retrievable IVC filter (although there was no visible clot in
the right iliac vein).
Upon arrival to the CCU, Mr. [**Known lastname **] [**Last Name (Titles) **] chest pain,
shortness of breath, or cough. Apart from being quite sweaty, he
feels like his normal self.
Past Medical History:
1. Non-ischemic cardiomyopathy
- Diffuse, global hypokinesis, LVEF 15% on [**2-/2124**] TTE
- Cardiac catheterization in [**2118**] wnl.
- s/p dual chamber guidant ICD implanted [**2120-3-25**] by [**Last Name (un) 31148**]
Koplan at [**Hospital3 **]; s/p lead extraction on [**2124-3-22**] (given
endocarditis/lead infection)/
2. Endocarditis: TEE on [**2124-3-13**] showed vegetations on the
tricuspid valve (1.3cm) and ICD wire (1.2). There was also
concern for < 1cm echodensity on aortic valve.
3. Atrial fibrillation, on coumadin
4. h/o NSVT
5. Embolic event to right lower extremity in [**12/2123**]
6. Non-insulin dependent diabetes mellitus -- patient [**Year (4 digits) **]
7. h/o diverticulitis complicated by peri-colonic abscess
([**2-/2124**])
- drained by IR [**3-9**], drain removed [**3-17**]
- Cx grew [**Female First Name (un) **] albicans, and he was treated w/ fluconazole
[**Date range (1) 60921**]
8. Hyperlipidemia
9. Hypertension
10. GERD
11. Anxiety
Social History:
Patient used to be a PE teacher for an elementary school in
[**Hospital1 8**]. He has been married for 39 years and has 6
grandchildren. He never smoked and drinks ~5 bottles of
beer/week.
Family History:
Mother with DM, alive at age 85. Father died of lung CA. No
family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: 97.3 90/62 93 26 96% 2L
GENERAL: Overweight man who is smiling but profusely sweaty.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of [**6-6**] cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. Irregularly irregular. Soft systolic murmur at LLSB. No
thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Obese. Wound dressing at prior drain site in LLQ. Bowel
sounds present. Soft and not tender. No mass appreciated.
EXTREMITIES: +pitting LE edema b/l.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
On the day of discharge, vital signs were: 97.6 (max. 97.9) F,
108/78 (91/74 - 116/81) mmHg, 100 (artifactually low [**Location (un) 1131**] of
41 in context of ectopy - 100) BPM, RR of 22 (minimum 20) and 94
% hemoglobin saturation on room air. Telemetry revealed two runs
of ventricular tachycardia of 30 beats, both near 5 p.m. last
night.
Physical exam findings were essentially unchanged, but for
transmitted upper airway sounds of loose mucus. No consolidation
or other signs of infection.
Pertinent Results:
ADMISSION:
[**2124-3-29**] 02:40PM BLOOD WBC-14.2* RBC-3.29* Hgb-10.2* Hct-32.2*
MCV-98 MCH-31.0 MCHC-31.7 RDW-15.6* Plt Ct-249#
[**2124-3-29**] 02:40PM BLOOD Neuts-88.1* Lymphs-6.8* Monos-4.7 Eos-0.2
Baso-0.2
[**2124-3-29**] 04:30PM BLOOD PT-49.9* PTT-40.3* INR(PT)-5.5*
[**2124-3-29**] 02:40PM BLOOD Glucose-105* UreaN-9 Creat-0.9 Na-135
K-4.2 Cl-98 HCO3-29 AnGap-12
[**2124-3-30**] 03:08AM BLOOD ALT-25 AST-18 LD(LDH)-249 CK(CPK)-9*
AlkPhos-98 TotBili-0.7
[**2124-3-30**] 03:08AM BLOOD Calcium-7.7* Phos-3.3 Mg-1.7
[**2124-3-30**] 03:18AM BLOOD %HbA1c-6.9* eAG-151*
[**2124-3-29**] 03:10PM BLOOD Lactate-1.3
[**2124-3-29**] 03:10PM BLOOD Lactate-1.3
DISCHARGE:
[**2124-4-8**] 06:00AM BLOOD WBC-10.4 RBC-3.83* Hgb-11.6* Hct-38.1*
MCV-100* MCH-30.3 MCHC-30.5* RDW-17.7* Plt Ct-345
[**2124-4-7**] 07:20AM BLOOD PT-19.6* PTT-58.8* INR(PT)-1.8*
[**2124-4-7**] 07:20AM BLOOD Glucose-114* UreaN-6 Creat-0.9 Na-140
K-4.4 Cl-103 HCO3-29 AnGap-12
[**2124-3-29**] 02:40PM BLOOD cTropnT-0.02*
[**2124-3-30**] 03:08AM BLOOD CK-MB-NotDone cTropnT-0.02*
REPORTS:
CTA CHEST [**2124-3-29**]:
1. Large pulmonary embolism involving distal right main
pulmonary artery
extending into all lobes of the right lung. Occlusion is
complete in the
right upper lobe posterior segment, and partially elsewhere.
Wedge posterior
right upper lobe parenchymal abnormality suggestive of pulmonary
infarct. No
CT evidence of right ventricular heart strain.
2. No acute aortic pathology.
3. Bilateral pleural effusions with overlying atelectasis.
4. Left upper lobe consolidation. Other pulmonary nodular
opacities as
above, measure up to 7 mm. Findings could be infectious, but
recommend
short-term followup in three-to-six months after appropriate
treatment to
assess for stability/resolution and exclude neoplastic process.
5. Possible trace perisplenic fluid, not well or fully assessed.
CARDIAC CATH [**2124-3-29**]:
1. Access was obtained at the left femoral vein using an 8 Fr
short
sheath.
2. Right pulmonary angiography was performed through a 5 Fr JR4
catheter. This showed an occlusive embolus in a right
subsegmental
branch. We exchanged the catheter to a 6 Fr MPA1 guide catheter
and
attempted to aspirate material. Aspirate was sent for
microbiologic
culture. Partial restoration of flow occurred. We next
advanced a
Prowater wire across the embolus and activated an Export AP
aspiration
thrombectomy catheter over several passes. Flow to the
pulmonary
segment improved substantially and the residual embolic material
was
left.
3. Venography performed via the left femoral vein sheath showed
no
apparent thrombus in the left iliac vein, proximal right iliac
vein, or
IVC.
4. An Optease Vena Cava filter was deployed in the IVC below the
renal
veins.
FINAL DIAGNOSIS:
1. Pulmonary embolus.
2. Partial embolectomy performed.
3. Placement of an IVC filter.
CT ABDOMEN [**2124-3-30**]:
1. Inflammatory changes surrounding sigmoid colon, consistent
with acute
diverticulitis. 2.9 cm intramural loculated air collection, some
of which may be extraluminal. As this is surrounded by small
bowel loops, this is not amendable to percutaneous drainage.
2. Findings that are consistent with third spacing, including
anasarca,
ascites, retroperitoneal fluid and effusions.
3. Gallbladder wall thickening is presumed to be related to the
same process, however, further evaluation with son[**Name (NI) **] followup
is recommended.
4. Bladder wall thickening, in part related to decompressed
bladder state. Correlate with urinalysis.
BL LE U/S [**2124-3-30**]:
FINDINGS: Grayscale, color and Doppler images were obtained of
bilateral
common femoral, superficial femoral, popliteal and tibial veins.
There is
normal flow, compression and augmentation seen in all of the
vessels.
IMPRESSION: No evidence of deep vein thrombosis in either leg.
BL UE U/S [**2124-3-30**]:
IMPRESSION: Extensive thrombus surrounding the IV line within
the left arm
extending from the antecubital fossa to the left axillary vein.
No other deep vein thrombosis seen in the right arm.
ECHO [**2124-3-31**]:
The left atrium is moderately dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is severe global left ventricular hypokinesis (LVEF = 15-20%).
The right ventricular cavity is moderately dilated with moderate
global free wall hypokinesis. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. No masses or vegetations are seen on the
aortic valve. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral valve. Mild (1+) mitral regurgitation is seen.
There is a large (3.0 x 1.3 cm) highly-mobile verrucous
tricuspid valve vegetation. Moderate to severe [3+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. No vegetation/mass is seen on the
pulmonic valve. There is a small pericardial effusion.
IMPRESSION: Large tricuspid valve vegetations. Moderate to
severe tricuspid regurgitation. Dilated left ventricle with
severe global systolic dysfunction. Moderate global right
ventricular systolic dysfunction. Moderate pulmonary
hypertension.
CARDIAC CATH [**2124-4-3**]:
1. Access was obtained at the right femoral vein. A 5 Fr 55cm
[**Last Name (un) **]
sheath was advanced. An Amplatz Gooseneck snare was advanced
and used
to capture the Optease IVC filter without difficulties.
2. We next turned our attention to removing the PICC from the
right
brachial vein. Through the [**Last Name (un) **] sheath in the right femoral
vein, we
advanced a 4 Fr JR4 catheter over a wire to the right subclavian
vein.
Venography with partial retrograde filling revealed thrombus.
We then
inserted an 0.032" wire through the PICC lumen and removed the
PICC. A
4 Fr short sheath was inserted over this wire. Venography
through this
sheath also showed extensive thrombus from the brachial to
axillary.
There was a long segment of occlusion with a large collateral
vein
bypassing it. We exchanged the brachial sheath to a 5 Fr 45cm
[**Doctor Last Name **] 0
over a Choice PT ES wire to perform Angiojet thrombectomy. Via
the
right femoral vein sheath, we advanced a [**Doctor Last Name 4726**] Flow reversal
balloon
tipped catheter to the subclavian and inflated the balloon until
cessation of flow occurred. We then performed Angiojet
thrombectomy
using a XVG catheter. Mild improvement in flow occurred.
However,
large thrombi remained. We performed balloon dilations of the
occlusive
segment using a 4.0x120mm Aphirion balloon at 8 atms and a
5.0x120mm
Submarine balloon at 4 atms and a 6.0x120mm Submarine balloon at
3 atms.
Venography showed a stenosis in the subclavian vein that we
dilated
using an 8x40mm Admiral balloon at 3 atms. Final venography
showed
persistent thrombi and slow flow in the previously occluded
segment.
Flow through the collateral vein was preserved.
FINAL DIAGNOSIS:
1. IVC filter retrieval.
2. PICC removal.
3. Right upper extremity deep venous thrombosis.
CTA CHEST [**2124-4-5**]:
Overall little interval change since [**2124-3-30**].
1. Inflammatory changes about the sigmoid colon with colonic
wall thickening and air collection in the region of the proximal
sigmoid colon which may be intramural/extramural is consistent
with diverticulitis and is unchanged since [**2124-3-30**].
2. Bilateral pleural effusions right greater than left unchanged
since [**2124-3-30**].
3. Ascites and retroperitoneal stranding is unchanged since
[**2124-3-30**].
CXR [**2124-4-7**]:
CHEST, AP: A new left PICC terminates 1-2 cm beyond the
cavoatrial junction. There is no pneumothorax. Left lower lobe
atelectasis has worsened, and a loculated right effusion is
increased. Multiple pulmonary nodules are present. Moderate
cardiomegaly is unchanged.
IMPRESSION: Left PICC 1-2 cm beyond cavoatrial junction.
Increased left
lower lobe atelectasis and right effusion.
Brief Hospital Course:
Mr [**Known lastname **] is a 62-year-old man w/ alcoholic CHF, AICD
placement, c/b endocarditis, AICD removed, PICC line placed for
Rx, with subsequent clot around PICC, despite anticoagulation,
who presented with dyspnea, hypotension, atrial fibrillation and
was found to have a PE. Right PICC removed and intravenous
heparin treatment commenced.
Pulmonary embolism/DVT
He presented with a PE in the setting of a supratherapeutic
INR. He underwent thrombectomy and was started on a heparin
drip, and an IVC filter was placed prophylactically. His PE was
thought to be embolic from fibrous material on his mitral valve
from his endocarditis. However, PICC line-associated DVT was
also noted and may be a more likely source of emboli. His PICC
was removed in the cath lab with use of a Swan-Ganz catheter and
clot retrieval to reduce further pulmonary thromboembolism.
However, a second PICC was placed on the contralateral side
prior to discharge for continuation of nafcillin for his MSSA
endocarditis. The IVC filter was removed after lower extremity
ultrasound did not reveal thrombus. Coumadin was restarted after
these procedures and when his INR was again just below 2,
restarted on [**2124-4-7**]. Hem.-Onc. recommended a hypercoagulability
workup if ever he is not anticoagulated. Given recurrent
thrombosis, he ought be treated with coumadin life-long, also
indicated by atrial fibrillation in this patient. Therefore,
this will only be important for the purpose of determining
genetic risk. More importantly, he will need age-appropriate
cancer screening, including colonoscopy and PSA. CT torso did
not reveal evident neoplasia.
Endocarditis
This developed in the context of AICD placement given dilated
cardiomyopathy and depressed ejection fraction for primary
prevention of serious arhythmia. The AICD was removed on [**3-20**]
and the endocarditis was complicated by valvular
incompetentence/destruction. He was initially on broad spectrum
antibiotics but eventually put on nafcillin. A repeat cardiac
echo demonstrated enlargement of vegetations and cardiothoracic
surgery was consulted but felt that he was not a candidate for
valvular revision or debridement. ID recommended continuing
nafcillin until [**4-18**] and he will follow-up with the [**Hospital **] clinic on
[**2124-5-5**].
Diverticulosis
This was seen on abdominal CT and he was briefly given
levofloxacin and flagyl. A repeat abdominal CT demonstrated no
significant changes and his antibiotics were stopped. He had no
abdominal pain.
Systolic Heart Failure/NSVT
He has chronic systolic heart failure with an LVEF 15-20%. He
was continued on metoprolol and lisinopril, and his ICD was
removed as above. He was seen by the electrophysiology service
and they recommended that he must wear a lifevest at rehab, and
that he does not need to be followed on telemetry provided he is
wearing his lifevest. Given the possible expense of the
life-vest, often not covered by insurance in acute settings,
such as LTAC, this may be revisited by LTAC physicians, in
conjunction with electrophysiology and the patient. We would
only recommend that this continue where there is not
continuously monitored telemetry. Electrolytes, particularly
potassium and magnesium should be followed closely, daily
initially, to insure that his chances of ventricular arhythmia
are reduced.
Atrial Flutter
He was continued on metoprolol and anticoagulated.
Dyslipidemia
Continued simvastatin.
Medications on Admission:
Warfarin
Lisinopril 2.5mg daily (although unclear if 1.25mg)
Carvedilol 25mg [**Hospital1 **] (was 25mg in AM and 50mg in PM at dc)
Digoxin 125mcg daily
Furosemide 20mg daily
Simvastatin 40mg QHS
Lansoprazole 30mg daily
Glipizide 2.5mg daily (was not on this at dc)
Docusate 100mg [**Hospital1 **]
Magnesium oxide 400mg [**Hospital1 **]
MVI with minerals daily
Niacin 500mg QHS
Trazodone 25mg QHS prn
Oxycodone 2.5mg prior to PT/OT (not being given)
Tylenol 650mg Q4H prn
Lorazepam 0.5mg Q9H prn
Lidoderm patch 5% daily (new)
Oxacillin 2g IV Q4H (this had been given in rehab. but there was
some initial concern that this had not been given)
Discharge Medications:
1. Digoxin 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at
bedtime).
3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
4. Nafcillin in D2.4W 2 gram/100 mL Piggyback [**Last Name (STitle) **]: Two (2) GM
Intravenous Q4H (every 4 hours): Last dose [**2124-4-18**] or until ID
recommends otherwise .
5. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
6. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
7. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
8. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
9. Warfarin 1 mg Tablet [**Month/Day/Year **]: Three (3) Tablet PO Once Daily at 4
PM.
10. Niacin 500 mg Capsule, Sustained Release [**Month/Day/Year **]: One (1)
Capsule, Sustained Release PO HS (at bedtime).
11. Multivitamin,Tx-Minerals Tablet [**Month/Day/Year **]: One (1) Tablet PO
DAILY (Daily).
12. Trazodone 50 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
13. Aspirin 81 mg Tablet, Chewable [**Month/Day/Year **]: One (1) Tablet, Chewable
PO DAILY (Daily).
14. Acetaminophen 325 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day/Year **]: One (1) Inhalation Q6H (every 6 hours) as
needed for congestion.
16. Ipratropium Bromide 0.02 % Solution [**Month/Day/Year **]: One (1) Inhalation
Q6H (every 6 hours) as needed for congestion.
17. Lisinopril 5 mg Tablet [**Month/Day/Year **]: 0.5 Tablet PO DAILY (Daily).
18. Lorazepam 0.5 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
19. Loperamide 2 mg Capsule [**Month/Day/Year **]: One (1) Capsule PO QID (4 times
a day) as needed for after each loose stool.
20. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup [**Month/Day/Year **]: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
21. Metoprolol Tartrate 50 mg Tablet [**Month/Day/Year **]: One (1) Tablet PO BID
(2 times a day).
22. Insulin Lispro 100 unit/mL Solution [**Month/Day/Year **]: One (1)
Subcutaneous ASDIR (AS DIRECTED): Sliding scale.
23. Ondansetron 4 mg Tablet, Rapid Dissolve [**Month/Day/Year **]: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for Nausea.
24. Heparin (Porcine) in NS 10 unit/mL Kit [**Month/Day/Year **]: One (1)
Intravenous Continuous: To treat PE. Goal PTT 60-100. Today's
PTT ([**2124-4-8**]) is 98. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital- [**Hospital1 8**]
Discharge Diagnosis:
Pulmonary Embolus
Deep venous thrombosis
Line infection
Infectious endocarditis
Ventricular tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to take care of you here at [**Hospital1 18**]. You were
admitted to the hospital for a pulmonary embolus, or blood clot
in your lung. This was thought to be due to a piece of the
infection on your heart valve breaking off and blocking the
arteries to the lungs. This clot was removed during a cardiac
catheterization. There was also an infection of your PICC line.
You will need to be on blood thinners for the rest of your life.
It is critical to your health to wear your lifevest at all
times.
We have made the following changes to your medications:
STOP taking carvedilol
START taking metoprolol
START albuterol and ipratropium nebulizers as needed for
shortness of breath
START taking a daily baby aspirin
START ativan as needed for anxiety
Continue nafcillin until [**2124-4-18**]
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs in 1 day or 6 pounds in 3 days.
Followup Instructions:
Infectious Disease:
Provider: [**First Name8 (NamePattern2) 4021**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2124-5-5**] 10:00
.
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] M. Phone: [**Telephone/Fax (1) 26774**] Date/time:
.
Elecrophysiology:
[**First Name8 (NamePattern2) **] [**Known firstname **], MD [**First Name (Titles) **] [**Hospital3 2568**]. Phone: Date/time:
|
[
"5119",
"4168",
"4280",
"42731",
"V5861",
"25000",
"2724",
"4019",
"53081"
] |
Admission Date: [**2192-11-24**] Discharge Date: [**2192-12-7**]
Date of Birth: [**2110-10-24**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Nitroglycerin
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
[**2192-11-28**] aortic valve replacement (23 mm CE pericardial)/
coronary artery bypass graft(SVG-RCA)/ ligation left atrial
apppendage/Maze
History of Present Illness:
This 82 year old Russian speaking female with known critical
aortic stenosis was admitted after a syncopal episode today
while at a museum. She was with her daughter and family friend,
she felt slightly dizzy and then had episode of loss of
consciousness where she fell into the arms of the family. There
was no trauma or head injury. The physician family friend
thought the patient was pulseless so she initiated CPR, but the
pt regained a pulse and consciousness within ~15 seconds. Pt
also had bowel and bladder incontinence during this episode.
Past Medical History:
hypertension
Dyslipidemia
Coronary artery disease
s/p circumflex [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 5303**] in [**Location (un) 4551**] ([**2186**]).
Critical aortic stenosis
Moderate mitral regurgitation.
Moderate tricuspid regurgitation.
chronic Atrial fibrillation.
s/p radical mastectomy [**2156**] with radiation and
adjuvant chemotherapy
Multinodular Goiter
Social History:
She does not smoke or drink. She is a retired physicist.
Family History:
noncontributory
Physical Exam:
Admission:
VS: T=98.0 BP=120/60 HR=98 RR=18 O2 sat=100RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: supple, no JVD
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. II/VI sys murmur throughout precordium.
No r/g. No thrills, lifts. No S3 or S4.
LUNGS: no breast tissue s/p old mastectomies, no pain to
palpation, Resp were unlabored, no accessory muscle use. CTAB,
no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
Prebypass
The left atrium is dilated. Mild spontaneous echo contrast is
present in the left atrial appendage. The left atrial appendage
emptying velocity is depressed (<0.2m/s). A probable thrombus is
seen in the left atrial appendage. The right atrium is
moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. There is severe symmetric left ventricular
hypertrophy. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is low normal (LVEF
50-55%). [Intrinsic left ventricular systolic function is likely
more depressed given the severity of valvular regurgitation.]
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the descending thoracic aorta. The aortic
valve leaflets are severely thickened/deformed. There is
critical aortic valve stenosis (valve area <0.8cm2). Trace
aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. Moderate (2+) mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. There is no
pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the
results on [**2192-11-27**] at 1000 am.
Post bypass
Patient is AV paced and receiving an infusion of phenylephrine.
Biventricular systolic function is unchanged. Bioprosthetic
valve seen in the aortic position. Leaflets move well and the
valve appears well seated. There is no aortic insufficiency.
Peak gradient across the valve is 6 mm Hg . There is moderate
mitral regurgitation. There is moderate tricuspid regurgitation.
Aorta intact post decannulation. The left atrial appendage has
been ligated.
[**2192-12-7**] 07:20AM BLOOD WBC-8.0 RBC-3.75* Hgb-11.1* Hct-33.4*
MCV-89 MCH-29.5 MCHC-33.1 RDW-15.5 Plt Ct-277
[**2192-12-7**] 07:20AM BLOOD PT-23.7* INR(PT)-2.3*
[**2192-12-7**] 07:20AM BLOOD PT-23.7* INR(PT)-2.3*
[**2192-12-6**] 05:52AM BLOOD PT-28.4* INR(PT)-2.8*
[**2192-12-5**] 04:58AM BLOOD PT-19.4* PTT-31.0 INR(PT)-1.8*
[**2192-12-4**] 06:37AM BLOOD PT-15.5* PTT-30.3 INR(PT)-1.4*
[**2192-12-3**] 04:36AM BLOOD PT-15.5* PTT-30.2 INR(PT)-1.4*
[**2192-12-2**] 04:17AM BLOOD PT-16.3* PTT-32.2 INR(PT)-1.4*
[**2192-12-1**] 03:46AM BLOOD PT-19.3* PTT-36.2* INR(PT)-1.8*
[**2192-12-7**] 07:20AM BLOOD Glucose-90 UreaN-19 Creat-1.1 Na-143
K-4.2 Cl-100 HCO3-34* AnGap-13
Brief Hospital Course:
The patient consented to surgery at this time, having refused in
[**Month (only) 359**] when initially seen by cardiac Surgery.Ms. [**Known lastname 5304**] was
taken to the Operating Room and underwent Aortic Valve
Replacement (#23mm Pericardial)/Coronary Artery Bypass Graft x
1(Saphenous vein grafted to Right Coronary Artery)/Suture
ligation of Left Atrial Appendage/MAZE procedure.Cardiopulmonary
Bypass time= 139 minutes. Cross clamp time= 110 minutes. Please
refer to Dr[**Last Name (STitle) 5305**] operative report for further details.
She weaned from bypass on Propofol and was transferred to the
CVICU. She awoke neurologically intact and was extubated without
difficulty. Beta-blocker and Amiodarone was initiated. Transient
junctional rhythm occurred and beta blocker was was temporarily
discontinued. Low dose Amiodarone was continued per Dr.[**Last Name (STitle) 171**].
POD#1 she was oliguric and had a metabolic acidosis which
required large volume resuscitation along with a Sodium
Bicarbonate drip. The acidosis resolved and she continued to
progress. The right CT continued to have copious drainage and wa
left in after mediastinal tubes and pacing wires were removed.
Low dose B-Blocker was reinstated and tolerated well. Dosing was
optimized for rate control.
Anticoagulation was resumed on POD#3 with Coumadin. Her rhythm
went back into Atrial Fibrillation and beta blocker was
increased.. POD#4 she was transferred to the step down unit for
further monitoring. Physical therapy was consulted for
evaluation and assesment. The CT continued to produce 2 liters
daily and a CXR revealed a trapped right lowere lobe. Dr.
[**Last Name (STitle) **] was consulted. The CT was clamped for 24 hours and
serial CXRs revealed filling of the basilar space with fluid,
but no significant accumulation or pneumothorax. The CT was
then opened, drained 50cc and removed.
Dr. [**Last Name (STitle) 5306**] has agreed to follow and manage Coumadin as before,
with an INR goal of [**2-7**]. Follow up with Drs. [**Last Name (STitle) 914**], [**Name5 (PTitle) 171**],
[**Name5 (PTitle) 5306**] and [**Doctor Last Name **] were arranged as well as the wound
clinic here.
A PA and lateral film demonstarted....
She was therapeutic on Coumadin and ready for discharge.
Arrangements were made for follow up, Coumadin will be
controlled by her primary care physician.
Medications on Admission:
Warfarin (dose-adjusted to INR [**2-7**])
Lipitor 10 mg daily
Aricept 5 mg nightly
enalapril 5 mg daily
metoprolol 100 mg twice daily
spironolactone 25 mg daily
torsemide 20 mg [**Hospital1 **]
aspirin 81 mg daily.
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
7. Enalapril Maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO Q12H (every 12
hours).
Disp:*60 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 weeks.
Disp:*30 Tablet(s)* Refills:*0*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
Aortic stenosis
coronary artery disease
s/p aortic valve replacement/coronary artery bypass
s/p circumlex stenting
mitral regurgitation
tricuspid regurgitation
chronic atrial fibrillation
hypertension
dyslipidemia
h/o breast cancer
s/p radical mastectomy [**2156**]
s/p chemotherapy and chest radiotherapy
multinodular goiter
Discharge Condition:
ambulatory, alert and oriented
Discharge Instructions:
no lotions, creams or powders on any incision
shower daily and pat incisions dry
call for fever greater than 100.5, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week
no driving for one month and off all narcotics
no lifting greater than 10 pounds for 10 weeks
take all medications as directed
Followup Instructions:
Dr. [**Name (NI) 5307**] in [**1-6**] weeks ([**Telephone/Fax (1) 5308**])
Dr. [**Last Name (STitle) 171**], appointment [**2192-12-19**] at 12:40pm
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) **] in 4 weeks (see same day as Dr. [**Last Name (STitle) 914**]
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
Completed by:[**2192-12-7**]
|
[
"5845",
"2762",
"5180",
"4241",
"42731",
"4280",
"41401",
"4019",
"2724",
"V5861"
] |
Admission Date: [**2123-8-19**] Discharge Date: [**2123-9-2**]
Date of Birth: [**2048-1-21**] Sex: F
Service: SURGERY
Allergies:
Gadolinium-Containing Agents
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Abdominal pain, vomiting
Major Surgical or Invasive Procedure:
[**2123-8-19**]: Exploratory laparotomy, small bowel resection, and
primary anastomosis
History of Present Illness:
Ms. [**Known lastname 16968**] is a 75F with h/o stage IV NSCLC diagnosed [**2121**], s/p
chemo, XRT, and recent STEMI s/p LAD BMS placement [**2123-7-30**],
presenting with acute onset LLQ pain associated with nausea and
vomiting. Symptoms began the early on the morning of admission,
and woke her from sleep. She reports several episodes of
nonbloody, bilious emesis at home prior to being transported to
[**Hospital1 18**] ED by EMS. She remembers passing flatus during the event,
and reports having had a normal bowel movement overnight. She
denies fevers or worsening shortness of breath.
Past Medical History:
Past Medical History: CAD s/p MI, LAD BMS [**2123-7-30**], CHF EF 30%,
HLD, NSCLC stage IV s/p chemo/XRT, HTN, GERD, macular
degeneration, anxiety, recent fall with spine fracture, managed
nonoperatively
Past Surgical History: None
Social History:
She lives in [**Location 8391**] with her son.
[**Name (NI) **]: 1ppd for years, but she has not smoked in many years, no
EtOH, no illicts. She is widowed, her husband passed away from
lung cancer.
Family History:
Mother passed away for CAD, heart failure in her 80s. Father
passed away at 62 yo from complications of diabetes. Sister has
CAD, heart failure (in her 80s). Had 7 brothers (2 died at 44
yo, one at 55 yo and one at 60 yo and had lung disease but she
doesn't know anything more specific. 1 brother died as a baby.
1 brother had [**Name2 (NI) 499**] cancer and is well. Her only son is
physically handicapped.
Physical Exam:
Physical Exam on Admission:
Vitals: 97.9 98 130/94 28 100%
GEN: A&O, uncomfortable but nontoxic, conversant
HEENT: No scleral icterus, mucus membranes moist
CV: Regular, tachycardic to 100s, +systolic murmur
PULM: Increased, rales bilaterally
ABD: Soft, moderately distended, +TTP in the suprapubic and LLQs
with voluntary guarding. No rebound tenderness. No palpable
masses. No scars. NG with scant output.
DRE: normal tone, no gross or occult blood
Ext: Trace LE edema, LE warm and well perfused
Physical Examination upon discharge:
VS: 98.1, 84, 126/54, 20, 100/RA
GEN: Sitting up in chair, NAD.
HENNT: No scleral icterus, mucus membranes moist
CARDIAC: Normal S1, S2 RRR No MRG.
PULM: Lungs diminished at bases. No W/R/R.
ABD: Soft/nontender/mildly distended. Healing abdominal
incision, erythema marked.
EXT: + pedal pulses.+ trace edema. Well perfused. No cyanosis,
clubbing.
Pertinent Results:
[**2123-8-19**] Radiology CT ABD & PELVIS WITH CO
IMPRESSION:
1. Small bowel obstruction with a transition point in left lower
quadrant. Just proximal to the transition point there is a 2.6 x
4.1 cm lobulated small bowel mass concerning for a metastasis
with a primary small bowel tumor in the differential diagnosis.
2. Interval increase in the size of the left adrenal metastasis.
3. Resolution of a right pleural effusion with a persistent
small left
pleural effusion.
4. Small amount of pelvic free fluid.
[**2123-8-25**] PORTABLE ABDOMEN
FINDINGS: Supine and decubitus views of the abdomen demonstrate
air-filled small and large bowel loops without frank
pneumoperitoneum or pneumatosis. Patient is status post recent
exploratory laparotomy with anterior abdominal surgical staples
in place. No air-fluid levels or focal bowel dilatation.
IMPRESSION: Findings suggest a component of postoperative
ileus.
[**2123-8-25**] 04:59AM BLOOD WBC-11.4* RBC-3.62* Hgb-9.6* Hct-30.1*
MCV-83 MCH-26.4* MCHC-31.8 RDW-16.5* Plt Ct-413
[**2123-8-24**] 05:56AM BLOOD WBC-12.9* RBC-3.88* Hgb-10.1* Hct-32.1*
MCV-83 MCH-26.0* MCHC-31.4 RDW-16.4* Plt Ct-444*
[**2123-8-23**] 05:54AM BLOOD WBC-11.5* RBC-3.63* Hgb-9.5* Hct-30.3*
MCV-84 MCH-26.1* MCHC-31.2 RDW-16.7* Plt Ct-428
[**2123-8-19**] 07:35AM BLOOD Neuts-87.3* Lymphs-5.6* Monos-4.0 Eos-2.8
Baso-0.2
[**2123-8-25**] 04:59AM BLOOD Glucose-123* UreaN-9 Creat-0.5 Na-142
K-3.7 Cl-106 HCO3-27 AnGap-13
[**2123-8-24**] 05:56AM BLOOD Glucose-130* UreaN-12 Creat-0.5 Na-142
K-3.0* Cl-103 HCO3-29 AnGap-13
[**2123-8-23**] 05:54AM BLOOD Glucose-68* UreaN-17 Creat-0.5 Na-141
K-4.0 Cl-106 HCO3-23 AnGap-16
[**2123-8-19**] 07:35AM BLOOD Glucose-130* UreaN-21* Creat-0.7 Na-138
K-4.1 Cl-103 HCO3-25 AnGap-14
[**2123-8-25**] 04:59AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.5*
[**2123-8-24**] 05:56AM BLOOD Calcium-7.8* Phos-2.2* Mg-1.8
[**2123-8-23**] 05:54AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.9
[**2123-8-20**] 12:50AM BLOOD Calcium-8.2* Phos-4.6* Mg-1.5*
[**2123-8-19**] 07:35AM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.1 Mg-1.8
[**2123-8-20**] 12:57AM BLOOD Lactate-1.2
[**2123-8-19**] 12:08PM BLOOD Lactate-1.6
[**2123-8-19**] 11:21PM BLOOD Hgb-7.5* calcHCT-23 O2 Sat-98
[**2123-9-1**] 04:29AM BLOOD WBC-11.6* RBC-3.36* Hgb-9.6* Hct-29.1*
MCV-87 MCH-28.5 MCHC-33.0 RDW-17.6* Plt Ct-391
[**2123-8-31**] 05:25AM BLOOD WBC-12.2* RBC-3.46* Hgb-9.7* Hct-29.9*
MCV-87 MCH-28.0 MCHC-32.4 RDW-17.3* Plt Ct-397
[**2123-8-30**] 01:22AM BLOOD WBC-10.9 RBC-3.23* Hgb-9.3* Hct-27.4*
MCV-85 MCH-28.8 MCHC-34.0 RDW-16.6* Plt Ct-319
[**2123-8-29**] 02:30AM BLOOD WBC-13.1* RBC-3.48* Hgb-10.0* Hct-28.9*
MCV-83 MCH-28.7 MCHC-34.5 RDW-16.1* Plt Ct-321
[**2123-9-1**] 04:29AM BLOOD Glucose-70 UreaN-7 Creat-0.6 Na-132*
K-4.3 Cl-101 HCO3-21* AnGap-14
[**2123-8-30**] 01:22AM BLOOD Glucose-113* UreaN-9 Creat-0.4 Na-135
K-3.9 Cl-107 HCO3-23 AnGap-9
[**2123-9-1**] 04:29AM BLOOD Calcium-7.7* Phos-3.4 Mg-1.7
[**2123-8-31**] 05:25AM BLOOD Calcium-7.4* Phos-3.5 Mg-1.8
[**2123-8-30**] 01:22AM BLOOD Calcium-7.3* Phos-2.5* Mg-1.9
Brief Hospital Course:
Ms. [**Known lastname 16968**] is a 75F with h/o stage IV NSCLC diagnosed [**2121**], s/p
chemo, XRT, and recent STEMI s/p LAD BMS placement [**2123-7-30**],
presenting with acute onset LLQ pain associated with nausea and
vomiting. The patient was admitted to the acute care surgery
service on [**8-19**] after imaging revealed that she had a small
bowel obstruction. Her INR was reversed with 1mg IV vitamin K
and 2u FFP to 1.5. After appropriate preparation, Ms. [**Known lastname 16968**] [**Last Name (Titles) 8783**]t exploratory laparotomy and small bowel resection,
which was uncomplicated. Post-operatively she was transferred
to the SICU for monitoring and extubation, given her EF of 30%
and intra-operative volume resuscitation. On [**8-20**], she was
successfully extubated without complication. She was continued
on her aspirin, plavix, and beta blockade perioperatively. Her
NGT was kept to suction awaiting return of bowel function. She
was well-saturated on room air, and deemed stable for transfer
to the surgical floor. After patient was transferred to the
floor, her nasogastric tube was discontinued and she was
advanced to clear liquids. She was restarted on her coumadin,
and had daily INR draws. On POD 6, her INR was 2.9 and coumadin
was held. The patient complained of nausea and had emesis so
diet wasn't advanced past clear liquids. She underwent an
abdominal Xray and imaging revealed no air however [**Month/Year (2) 499**] had
dilatation. The patient received Dulcolax suppositories. On POD
7, INR had increased to 10.1 and patient received Vitamin 5mg to
reverse. Her hematocrit trended from 30.9, 27.7, 23.9 and
patient was transfused with 2 units packed red blood cells at
which time she was transferred back to the ICU for a lower GI
bleed. She has three large melena stools before transfer.
Cardiology was consulted and recommended discontinuing warfarin
secondary to risks outweighing the benefits, and holding aspirin
and plavix until bleeding has resolved. The patient's hematocrit
increased to 26 status post transfusion. Patient had serial
hematocrits drawn, and on POD 8 her hematocrit was 23 and she
received an additional 2 units packed red blood cells. She was
kept NPO and given zofran and phenergan for nausea. Her urine
culture grew Klebsiella so the patient was started on
appropriate antibiotics. Aspirin and Plavix were restarted in
the ICU prior to patient's transfer back to the floor, when her
hematocrit was 28.9 and stable. Upon arrival to the floor, the
patient's vitals remained stable and patient was afebrile. She
was tolerating a regular diet but complained of intermittent
nausea. She was voiding a large amount of urine appropriately.
On the day of discharge, we marked the erythema on your
abdominal incision in order to monitor if it worsens. The
patient will continue on PO Bactrim for 3 more days for her
urinary tract infection. The patient will follow up with
Cardiology outpatient as well as the [**Hospital 2536**] Clinic in 2 weeks.
Medications on Admission:
Aspirin 81'
plavix 75'
coumadin 2.5'
omeprazole 40'
atorvastatin 80'
benzonatate 100''' PRN
folate 1'
ativan 0.5 q6 PRN
metoprolol XL 150'
quinapril 10'
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Metoprolol Succinate XL 150 mg PO DAILY
6. Quinapril 10 mg PO DAILY
7. Sulfameth/Trimethoprim DS 1 TAB PO BID
8. Senna 1 TAB PO BID:PRN constipation
9. Acetaminophen 1000 mg PO Q6H
10. Bisacodyl 10 mg PR DAILY:PRN constipation
11. Caphosol 30 mL ORAL QID:PRN oral mucositis
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 731**] - [**Location 8391**]
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted to the hospital for abdominal pain. Upon
imaging, it was revealed that you had a small bowel obstruction
and you were taken to the operating room for a small bowel
resection. Post-operatively, you developed a gastrointestinal
bleed and you were transfused with several units of blood. You
will be going to rehab for physical therapy and you will
continue your antibiotics for your urinary tract infection. You
will followup in the [**Hospital 2536**] Clinic, as well as with Hemaotologist
and a new Cardiologist.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-8**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2123-9-15**] at 9:40 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: THURSDAY [**2123-9-16**] at 4:15 PM
With: ACUTE CARE CLINIC with Dr [**First Name4 (NamePattern1) 5877**] [**Last Name (NamePattern1) 16471**]
Phone:[**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2123-9-7**]
|
[
"5990",
"41401",
"4280",
"4019",
"53081",
"2720",
"V4582",
"V5861",
"V1582"
] |
Admission Date: [**2130-7-22**] Discharge Date: [**2130-7-28**]
Date of Birth: [**2130-7-22**] Sex: F
Service: Neonatology
HISTORY: [**Known lastname **] [**Known lastname 51634**] is the former 1.84 kg product of a
34-5/7 week gestation pregnancy born to a 32-year-old gravida
2, para 0 woman.
PRENATAL SCREENS: Blood type O+, antibody negative, rubella
immune, RPR nonreactive, hepatitis B surface antigen
negative, group beta strep negative.
The pregnancy was notable for dichorionic, diamniotic twins.
The pregnancy was uncomplicated until [**2130-5-27**] when the mother
developed hypertension. On the day of delivery she went into
spontaneousl labor and was allowed to deliver. The infant
was born by spontaneous vaginal delivery under epidural
anesthesia. There was no maternal fever. Rupture of
membranes occurred 16 hours prior to delivery. Apgar scores
were 8 at one minute and 9 at five minutes. The infant was
admitted to the Neonatal Intensive Care Unit for treatment of
prematurity.
PHYSICAL EXAMINATION: Examination upon admission to the
Neonatal Intensive Care Unit was weight 1.84 kg, 25th
percentile; length 43 cm, 25th percentile; head circumference
32 cm, 75th percentile. In general she was a pink, alert
baby breathing comfortably in room air. Skin was warm and
dry, color pink, no rashes or lesions. HEENT showed anterior
fontanel soft and flat, prominent molding, sutures mobile,
palate intact. Chest showed breath sounds to be clear and
equal. Cardiovascular had S1 and S2 with normal intensity,
no murmur, well perfused, pulses normal. Abdomen was soft
with normal bowel sounds, no organomegaly. Genitourinary
examination showed a normal female. Anus slightly small and
anteriorly placed, patent. Neurological examination showed
excellent tone, symmetrical movement of upper and lower
extremities.
HOSPITAL COURSE: 1. Respiratory: [**Known lastname **] was in room air
throughout her entire Neonatal Intensive Care Unit admission.
She had no episodes of spontaneous apnea.
2. Cardiovascular: [**Known lastname **] maintained normal heart rates and
blood pressures. During admission there were no
cardiovascular issues.
3. Fluids, electrolytes and nutrition: Enteral feedings were
started on day 1 of life. She has been on all p.o. feedings
during admission. She takes approximately 150-174 cc per kg
per day of Enfamil 20. Recent weight is 1.875 kg with a
length of 43.8 cm and a head circumference of 32 cm.
4. Infectious disease: Due to the preterm labor, [**Known lastname **] was
evaluated for sepsis. A white blood cell count was 12,200
with a differential of 37% polys, 5% bands. A blood culture
was obtained and was no growth at 48 hours.
5. Hematologic: Birth hematocrit was 49.6%. [**Known lastname **] did not
receive any transfusions of blood products.
6. GI: [**Known lastname **] required treatment for unconjugated
hyperbilirubinemia with phototherapy. Her peak serum
bilirubin occurred on day of life two with a total of 9.1/0.3
direct mg per dL. She received phototherapy for
approximately 72 hours. Her rebound bilirubin on [**2130-7-27**]
was 7.8 total with 0.2 direct mg per dL.
7. Neurology: [**Known lastname **] has maintained a normal neurological
examination during admission and there are no neurological
concerns at the time of discharge.
8. Sensory: Hearing screening was performed with automated
auditory brainstem responses. [**Known lastname **] passed in both ears.
CONDITION ON DISCHARGE: Good.
DISCHARGE DISPOSITION: The babies were transferred to the
Newborn Nursery on [**2130-7-28**] to board as their mother was
hospitalized for a possible infection.
PRIMARY PEDIATRICIAN: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 51635**], 42nd Avenue,
Suite #400, [**Hospital1 **], [**Numeric Identifier 51636**], phone number [**Telephone/Fax (1) 51637**],
fax number [**Telephone/Fax (1) 51638**]. Appointment is scheduled for Monday
[**2130-7-31**].
CARE AND RECOMMENDATIONS ON DISCHARGE:
1. Ad lib p.o. feeding, Enfamil 20 with iron.
2. No medications.
3. Car seat position screening was performed successfully
with adequate oxygen saturations for 90 minutes.
4. State newborn screen was sent on [**2130-7-25**] and a repeat on
[**2130-7-28**]. No notification of abnormal results to date.
5. No immunizations received to date; plan to receive
hepatitis B vaccine at the pediatrician's office.
6. Immunizations recommended:
A. Synagis RSV prophylaxis should be considered from
[**Month (only) 359**] through [**Month (only) 547**] for infants who meet any of the
following three criteria: Born at less than 32 weeks. Born
between 32 and 35 weeks with plans for day care during RSV
season with a smoker in the household or with preschool
siblings.
B. Influenza immunization should be considered annually in
the fall for preterm infants with chronic lung disease once
they reach six months of age. Before this age the family and
other caregivers should be considered for immunization
against influenza to protect the infant.
7. Follow-up appointment with Dr. [**Last Name (STitle) 51635**] on [**2130-7-31**].
DISCHARGE DIAGNOSES:
1. Prematurity at 34-5/7 weeks gestation.
2. Twin #1 of twin gestation.
3. Suspicion for sepsis ruled out.
4. Unconjugated physiologic hyperbilirubinemia.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 37237**], M.D. [**MD Number(1) 37238**]
Dictated By:[**Last Name (Titles) 37548**]
MEDQUIST36
D: [**2130-7-22**] 05:32
T: [**2130-7-28**] 07:05
JOB#: [**Job Number 51639**]
|
[
"7742",
"V290"
] |
Admission Date: [**2138-6-26**] Discharge Date: [**2138-6-30**]
Date of Birth: [**2105-5-12**] Sex: F
Service: Trauma Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 33-year-old
restrained driver in a rollover motor vehicle crash on the
way home from her methadone clinic. This was the patient's
third motor vehicle crash in the past month. There was a
prolonged extrication time from the vehicle. The patient was
found to have a blood pressure of 50/palpation on the scene
and complained of left shoulder pain with loss of
consciousness. On transport via Med Flight, the patient had
a systolic blood pressure of 140 and GCS of 15 on arrival at
[**Hospital6 256**].
PAST MEDICAL HISTORY:
1. Crohn's disease
2. Arthritis
3. Depression
MEDICATIONS:
1. Methadone
2. Ativan
3. Xanax
4. Klonopin
5. Prozac
PAST SURGICAL HISTORY: Laparotomy for Crohn's disease
SOCIAL HISTORY: History of intravenous drug abuse. Last
heroin use was seven years ago, currently on methadone.
ALLERGIES: No known drug allergies.
EXAM ON PRESENTATION:
VITAL SIGNS: Temperature 36.9??????C, blood pressure 102/89,
heart rate ranged from 110 to 80, respiratory rate ranged
from 28 to 18, 100% oxygen saturation on a 100% nonrebreather
mask.
GENERAL: The patient was awake, answering questions, but
uncooperative.
HEAD, EARS, EYES, NOSE AND THROAT: Head was atraumatic.
Pupils were equal, round and reactive to light.
NECK: There was no distention of the neck veins. Trachea
was midline.
CHEST: Clear to auscultation bilaterally. Tender over the
left shoulder with ecchymosis of the left deltoid area.
HEART: Regular rate and rhythm.
ABDOMEN: Soft, nontender, nondistended with an old healed
surgical scar in the midline.
BACK: There were no wounds, no step-offs, no tenderness.
RECTAL: Positive tone, negative blood, negative guaiac.
INITIAL LABS: White count 50, hematocrit 29, platelet count
162. INR 1.3, sodium 140, potassium 3.8, chloride 103,
bicarbonate 30, BUN 7, creatinine 0.5, glucose 85. HCG
negative. Urine toxicology screen was positive for
benzodiazepines, methadone, cocaine and opioids which may
have been secondary to fentanyl given as part of her medical
care.
IMAGING: A head CT showed a para-falcine subarachnoid
hemorrhage and swelling over the right temporal and occiput.
Chest x-ray showed a comminuted left clavicle fracture.
Cervical spine x-ray showed no evidence of fracture or
malalignment, but was limited by partial visualization of C6
and C7. Thoracic lumbar spine films showed no fractures or
malalignment. Pelvis x-ray was negative. Right foot x-ray
was negative. Right ankle x-ray was negative. Left shoulder
x-ray showed a clavicular fracture. An MRI of the cervical
spine was performed, given the limitations of the cervical
spine films and tenderness on physical exam of the cervical
spine. The MRI showed mild to moderate disc bulging at the
C5-6 and C6-7 levels indenting the thecal sac without
compression of the spinal cord or foramina. There was no
evidence of bone or ligamentous injury or extrinsic spinal
cord compression or intrinsic spinal cord abnormalities. A
repeat head CT done on hospital day 2 showed a slight
interval decrease in the para-falcine subarachnoid hemorrhage
and a new air fluid level within the sphenoid sinus,
otherwise unchanged from the previous study.
HOSPITAL COURSE: The patient was admitted to the Trauma
SICU. She was evaluated by Neurosurgery who recommended no
intervention, just observation. Orthopedics evaluated her
for the left clavicle fracture and did not recommend surgical
intervention at this time. The patient continues to have
tenderness over her cervical spine for several days. MRI was
negative and she was eventually cleared clinically by the
trauma team in the presence of the trauma attending
physician. [**Name10 (NameIs) **] patient was transferred to the trauma surgery
floor. The patient had no complications during the rest of
her hospital stay. Her pain medications were weaned from
opioids to NSAIDS due to the requirement that she not have
any opioids on board besides methadone in order to qualify
for her methadone treatment. The patient was given
methadone. The patient was met and evaluated by Social Work
and discussed substance abuse treatment options. Her diet
was advanced and physical activity was advanced. The patient
progressed well on those fronts.
DISCHARGE PLAN: The patient will be offered inpatient
substance abuse rehabilitation by Social Work and a
disposition plan will be developed between the patient and
Social Work on [**2138-6-30**], so the patient will be discharged
either to inpatient treatment or to home.
DISCHARGE DIAGNOSES:
1. Para-falcine subarachnoid hemorrhage
2. Left comminuted clavicle fracture
FOLLOW UP PLAN: The patient can follow up in Trauma Clinic
in two weeks at ([**Telephone/Fax (1) 18746**].
DISCHARGE MEDICATIONS:
1. Methadone 70 mg q day
2. Ibuprofen 600 mg po tid with food
3. Prozac 40 mg po qd
4. Albuterol 1 to 2 puffs q6h prn
5. Klonopin 1 mg po bid
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**]
Dictated By:[**Doctor Last Name 38667**]
MEDQUIST36
D: [**2138-6-30**] 08:06
T: [**2138-6-30**] 08:18
JOB#: [**Job Number 42932**]
|
[
"311"
] |
Admission Date: [**2167-9-19**] Discharge Date: [**2167-10-8**]
Date of Birth: [**2167-9-19**] Sex: F
Service: NEONATOLOGY
Thank you for accepting the care of this 18-day-old girl.
The patient was born at 29+1 week gestation weighing 1,170
grams. She was the product of a natural di/di twin
pregnancy. She is twin two. She was born by spontaneous
vaginal delivery to a 34-year-old G2, P1, and prenatal
screens O positive, antibody negative, hepatitis B surface
antigen negative, RPR nonresponsive, rubella immune, GBS
negative. The pregnancy was complicated by an episode of
preterm labor two weeks prior to delivery. The mother was
treated with magnesium sulfate. She was subsequently sent
home. She arrived again on the day of delivery in preterm
labor despite aggressive tocolysis. The labor progressed.
Rupture of membranes occurred at delivery. The infant was
born active with spontaneous respirations and required
blow-by 02. Her Apgar scores were eight and eight. One dose
of betamethasone was given on the morning prior to delivery.
She was transferred to the NICU for further management of her
prematurity.
Her weight was 1,170 grams and she appears nondysmorphic.
She was noted to have respiratory distress with flaring,
grunting, and retractions. There was fair air entry
bilaterally. Her pulses were regular rate and rhythm. She
had no audible murmurs with normal heart sounds. Her
femorals were easily palpable. The abdomen was benign. Her
anterior fontanelle was soft, open, and flat. Her tone,
however, was appropriate for gestational age. She was moving
all of her extremities. Capillary refill was normal.
HOSPITAL COURSE: 1. RESPIRATORY: In view of her initial
respiratory distress, the infant was placed on CPAP. Her
clinical symptoms and radiological findings were consistent
with hyaline membrane disease. She required to be intubated
and received two doses of Surfactant. She was extubated by
the end of day of life number one. She was initially in room
air for a couple of days but then developed an oxygen
requirement and had to be placed back on CPAP on day of life
number five. She came off CPAP on day of life number 13 onto
nasal cannula oxygen. She went into room air on day of life
number 18 and has remained stable.
She has apnea of prematurity which was noticed on day of life
number one. She was given caffeine and is currently on about
8 mg/kilogram. She has between four and eight spells per day
which are mainly self-responsive but occasionally require
some stimulation.
2. CARDIOVASCULAR: She has remained cardiovascular stable
throughout this admission. She was noted to have a grade
I-II/VI systolic ejection murmur which was notable on day of
life number 12. She had an echocardiogram which revealed no
evidence of a PDA, although she did have a PFO.
She has had no cardiovascular issues apart from this.
3. FLUIDS, ELECTROLYTES, AND NUTRITION: She was initially
n.p.o. and commenced on hyperalimentation. Feeds were
initiated on day of life number two. She was advanced to
full feeds by day of life number nine and has been
progressing well in view of poor weight gain. Her caloric
density was advanced to 28 calories; however, in light of her
first newborn screen showing abnormalities which may
represent generous aminoacid supplementation in her
hyperalimentation we have not started ProMod. We are
currently awaiting the results of her follow-up newborn
screen which should be available today.
4. GASTROINTESTINAL: She developed hyperbilirubinemia of
prematurity and required phototherapy on day of life number
two. We discontinued phototherapy on day of life number
nine. The maximum bilirubin was 6.4 on day of life number
four. She has had no other issues.
5. HEMATOLOGY: Her initial hematocrit was 53.9. Her
follow-up hematocrit was 44 on [**2167-10-1**]. She has not
required any transfusions during this admission.
6. INFECTIOUS DISEASE: She had an initial sepsis
evaluation. There was no left shift on her CBC. Her blood
cultures were negative. Antibiotics were discontinued after
48 hours. She has had no ID issues since then.
7. NEUROLOGY: She has had two head ultrasounds on day of
life number five and yesterday which were both within normal
limits.
8. SENSORY/AUDIOLOGY: She will require a hearing screen
prior to discharge.
9. OPHTHALMOLOGY: She will require evaluation for ROP.
CONDITION AT TRANSFER: Stable in room air with apnea of
prematurity, on caffeine.
DISCHARGE DISPOSITION: [**Hospital3 **].
PRIMARY PEDIATRICIAN: Undecided.
CARE AND RECOMMENDATIONS:
1. Feeds at discharge: Breast milk 28 (without ProMod).
Calories made up of 4 calories per ounce of HMF and 4
calories per ounce of MCTO.
2. Medications: Vitamin E 5 international units
PG q.d.; ferrous sulfate 2 mg/kilogram PG q.d.
3. Car seat position screening: Will require prior to
discharge.
4. State newborn screening status: Initial screen abnormal
with repeat screen pending. The results should be available
today ([**10-8**]). The screen showed elevated PKU, homocystinuria
and MSUD screens. State lab felt this most c/w parenteral
nutrition effect. 5. Immunizations received: None.
6. Immunizations recommended: As per AAA recommendation,
Synagis RSV prophylaxis should be considered from [**Month (only) 359**]
through [**Month (only) 547**] for infants who meet any of the following three
criteria: 1) Born at less than 32 weeks. 2) Born between
32 and 35 weeks with plans for DayCare during RSV season,
with a smoker in the household, or with preschool siblings.
3) Chronic lung disease. Influenzae immunizations should be
considered annually in the fall for preterm infants with
chronic lung disease once they reach six months of age.
Before this age, the family and other caregivers should be
considered for immunization against Influenzae to protect the
infant.
FOLLOW-UP APPOINTMENTS RECOMMENDED: She will require
follow-up with her pediatrician. She will require follow-up
for retinopathy of prematurity. She will require follow-up
head ultrasound. If her newborn screening comes back
positive, she should be commenced on ProMod as well as her
sister to maximize caloric intake.
DISCHARGE DIAGNOSIS:
1. Prematurity.
2. Twin pregnancy (second twin).
3. Hyaline membrane disease.
4. Sepsis evaluation.
5. Left PPF.
6. Hyperbilirubinemia of prematurity.
7. Apnea of prematurity.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 36142**], M.D. [**MD Number(1) 36143**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2167-10-8**] 09:07
T: [**2167-10-7**] 19:52
JOB#: [**Job Number 50833**]
|
[
"7742",
"V290"
] |
Admission Date: [**2145-4-12**] Discharge Date: [**2145-4-24**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
NIPPV
cardiac catheterization s/p stents to L subclavian and iliac
History of Present Illness:
82 yo woman with extensive vascular history (below), breast
cancer in the past s/p L mastectomy in [**2128**], htn, high chol, and
possible diagnosis of colon cancer treated 2 yrs ago with chemo
which she self-d/c'ed, who had presented for elective
angiography for lower extremity ischemia, and had developed
nausea felt to be angina equivalent. After heparin gtt, she
went for cardiac cath on [**4-14**] PM and was found to have patent
grafts and 3vd, though low flow to LIMA and RLE vessels, thus
s/p stenting of right CIA and L subclavian. She developed left
sided weakness since then, unknown last well time. Heparin was
used prior to the cath, which was stopped at noon on [**4-15**]; she
did well during the procedure, although post-procedure there was
a groin hematoma and hematocrit drop requiring 2 units prbc's.
She moved well on exam last night. This morning, there was no
neuro exam performed, but she was apparently talking, with
no facial droop and normal language (?8 or 9AM). Cardiovascular
exam was considered to be stable. Just after 9AM she was seen
by the nurse, who found her to be unresponsive to voice; soon
afterwards, she had returned to [**Location 213**]. At 11AM she was seen by
the resident and appeared to have, once more normal language and
speech, but she was not moving the right side of her body.
Neuro
was contact[**Name (NI) **] at 11:15 and arrived at 11:30AM. Initial NIHSS
was unscorable because the patient was able to open eyes, but
did not speak at all, did not blink to threat on the left,
withdrew minimally to noxious stimuli (decreased on the left
upper extremity). DTRs were [**Name2 (NI) 19912**] at the knees and toes were
mute.
She was seen ten minutes later and language function was back to
normal with normal naming and speech, but a dense homonomous
hemianopsia, extinction to double simultaneous stimulation over
the left hemibody, weakness of the left arm, NIHSS of 5. On
further questioning later with family present, "peripheral
vision on the left" has been worse over the past month, though
she also has cararacts.
Past Medical History:
-HTN
-High chol
-PVD
-CAD s/p CABG x 4V [**2137**], no MI
-Breast cancer s/p L mastectomy [**2128**]
-Anemia
-TAH [**2109**]
-R->L fem-[**Doctor Last Name **] bypass
-Cataract surgery
-??Dx colon cancer 2 yrs ago s/p chemo, which pt d/c'ed because
of nausea
Social History:
She lives alone, is a nonsmoker, son lives nearby and is
involved with her care; daughter in [**Name2 (NI) **].
Family History:
Unknown.
Physical Exam:
Examination:
T 100.1 (had temp>101 earlier), bp 102/38, rr 18, 96%RA
General: white female, NAD
Heart: regular rate and rhythm with III/VI SEM RUSB, radiation
to
bilateral carotids vs bruits
Lungs: clear to auscultation anteriorly bilaterally
Abdomen: soft, nontender +bs
Extremities: warm, well-perfused
Mental Status: The patient was initially not speaking at all,
staring but not following commands; ten minutes later, she was
oriented to self, [**Hospital1 **], with intact language (no errors, normal
repetition) and normal speech. She was able to follow
multi-step
commands, and naming was intact. There was no apraxia or
agnosia.
Cranial Nerves: PERRLB 3->2, EOMI with no nystagums, +dense left
homonomous hemianopsia. Sensation on the face is intact to
light
touch but there is extinction on the left cheek to DSS. Facial
movements are normal and symmetrical. Hearing is intact to
finger
rub. The palate elevates in the midline. The tongue protrudes in
the midline and is of normal appearance.
Motor System: Bulk is normal; tone thought initially to be
increased x bilat arms when pt first seen but was likely flexor
tonic posturing during seizure; there is weakness in the left
arm
with 4/5 delt, and [**4-11**] triceps, [**5-12**] biceps, weak hand grasp,
left
sided pronator drift; there is also 4+/5 weakness of the
contralateral deltoid but elswhere in the right upper extremity
strength was normal. The patient can lift both legs off the bed
and hold them for over 5 seconds. There is no tremor.
Reflexes: The tendon reflexes are present, [**Month/Day (1) 19912**] in the knees
with bilaterally mute toes and normal.
Sensory: Sensation is present on the left side of the body, but
the patient has left hemibody extinction to DSS.
Coordination: There is some dysmetria of left finger to nose and
[**Doctor First Name **] in proportion to weakness.
Gait: Gait was not assessed.
Pertinent Results:
[**2145-4-12**] 07:30PM PT-11.7 PTT-21.6* INR(PT)-1.0
[**2145-4-12**] 07:30PM PLT COUNT-396
[**2145-4-12**] 07:30PM WBC-9.7 RBC-2.81* HGB-9.1* HCT-27.9* MCV-99*
MCH-32.5* MCHC-32.7 RDW-16.9*
[**2145-4-12**] 07:30PM CALCIUM-11.9* PHOSPHATE-3.1 MAGNESIUM-1.6
[**2145-4-12**] 07:30PM GLUCOSE-242* UREA N-36* CREAT-1.4* SODIUM-140
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
[**2145-4-12**] 07:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2145-4-12**] 07:52PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013
[**2145-4-12**] 07:52PM URINE GR HOLD-HOLD
[**2145-4-12**] 07:52PM URINE HOURS-RANDOM
Pre-procedure CXR:
PA AND LATERAL CHEST FILMS: Lung volumes are at the upper limit
of normal. The heart size is normal. Mediastinal and hilar
contours are unremarkable. Patient is status post sternotomy.
Prominent costochondral calcifications. Lung fields demonstrates
a 7mm in the left lung fields, may be a calcified granuloma.
Right basilar nodular opacity is probably a nipple shadow. There
are no pleural effusions. There is biapical pleural
calcification.
IMPRESSION: Right upper and basilar nodules. Right basilar
nodule is probably a nipple shadow. Comparison with prior films
recommended. In the absence of prior films, chest CT recommended
for the right upper nodule.
[**4-12**]:
CAROTID SERIES COMPLETE.
REASON: Bruit.
FINDINGS: Duplex evaluation was performed of both carotid
arteries. Moderate plaque is identified bilaterally. It is
somewhat calcified.
On the right, peak systolic velocities are 123, 94, 253 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.3.
This is consistent with 40 to 59% stenosis.
On the left, peak systolic velocities are 152, 89, 166 in the
ICA, CCA, and ECA respectively. The ICA to CCA ratio is 1.7.
This is consistent with a 60 to 69% stenosis.
There is antegrade flow in both vertebral arteries.
IMPRESSION: Moderate plaque with a left 60 to 69% and a right 40
to 59% carotid stenosis.
VENOUS DUPLEX, UPPER AND LOWER EXTREMITY.
REASON: Patient in need of bypass.
FINDINGS: Duplex evaluation was performed of both upper and
lower extremities. Left greater saphenous vein is patent with
diameters ranging from 0.17 to 0.45 cm. The saphenous vein below
the knee is somewhat diminutive.
Right cephalic vein is patent with diameters ranging from 0.24
to 0.30 cm. The right basilic vein is patent with diameters
ranging from 0.35 to 0.49 cm.
The left cephalic vein is not visualized. The left basilic vein
is patent with diameters ranging from 0.18 to 0.46 cm.
IMPRESSION: Patent left greater saphenous vein with somewhat
diminutive features below the knee. Patent bilateral basilic
veins and right cephalic veins with diameters as noted.
[**4-14**]: ABDOMINAL MRI/A
ABDOMINAL MRA: The aorta is normal in caliber. Diffuse
mild-to-moderate plaque is seen throughout the visualized
abdominal aorta including a more severe focal plaque
approximately 2 cm inferior to the renal arteries resulting in
narrowing of 50%. Celiac axis is normal. The origin of the SMA
is normal; however, multiple moderate focal stenoses are seen
within the visualized portion of the SMA. There is severe
stenosis at the origin of the left renal artery and
moderate-to-severe stenosis at the origin of the right renal
artery.
At the origin of the right common iliac artery, there is focal
high-grade stenosis and possible short segment occlusion. No
significant disease is seen within the remainder of the right
common iliac artery. Mild irregularity is seen within the right
external iliac artery.
There is complete occlusion of the left common iliac artery.
The right common femoral artery appears normal. There is a
patent femoral- femoral bypass graft. Retrograde flow is seen
within severely diseased external iliac and common femoral
arteries on the left.
RIGHT LOWER EXTREMITY MRA: Severe multifocal narrowing is seen
throughout the right SFA and popliteal arteries. Below the knee,
there is single vessel run off. The anterior tibial artery
demonstrates a few mild focal stenoses and terminates at the
level of the ankle. Minimal flow is seen within a severely
diseased dorsalis pedal artery. The DP artery is not directly
supplied by the AT artery. Minimal flow is seen within severely
diseased peroneal and posterior tibial arteries. Both vessels
occlude in the proximal to mid calf.
LEFT LOWER EXTREMITY: Severe multifocal disease is seen
throughout the left SFA and popliteal arteries. Blooming
artifact from a clip at the femoral- femoral bypass results in
non-visualization of the proximal SFA. Below the knee, there is
two-vessel run off. Mild-to-moderate multifocal disease is seen
within the tibioperoneal trunk which supplies patent posterior
tibial and peroneal arteries. The PT artery continues as a
plantar arch. The peroneal artery terminates in the distal calf.
A severely diseased anterior tibial artery occludes proximally.
IMPRESSION:
1. Diffuse atheromatous disease within the aorta.
2. Bilateral renal artery stenosis, left side greater than
right.
3. Focal high-grade stenosis (and possibly short segment
occlusion) at the origin of the right common iliac artery. Total
occlusion of the left common iliac artery.
4. Patent fem-fem graft
5. Severe multifocal disease within both thighs, as described
above.
6. Single vessel run off on the right with minimal flow in a
severely diseased dorsalis pedal artery.
6. Two-vessel run off on the left.
Evaluation of the reformatted images on a separate workstation
was valuable in delineating the anatomy.
CARDIAC CATH REPORT [**4-14**]:
COMMENTS:
1. Selective coronary angiography revealed a right dominant
system
with severe three vessel coronary artery disease. The LMCA, the
LCX, and
the RCA had proximal occlusions. The LAD had flow from the [**Female First Name (un) 899**].
The OM
system filled via collaterals from the LAD. The PDA and PLB had
no
angiographically apparent flow limiting lesions.
2. Selective graft venography revealed a patent SVG to RCA.
The SVG
to OM1 had an occlusion at the origin. The SVG to D1 to D2 had a
touchdown lesion in the D1.
3. Selective arterial conduit angiography revealed a patent
LIMA to
LAD.
4. Peripheral angiography showed an 80% origin stenosis of
the right
CIA and an occluded left CIA. The fem-fem graft was patent with
flow to
the left CFA. The right SFA had a 99% origin stenosis with slow
flow
with occlusion of the SFA at the adductor canal. The left
subclavian
artery had a 70% eccentric lesion with a pressure gradient of 10
mmHg
after the administration of NTG.
5. Resting hemodynamics demonstrated normal right, pulmonary,
and
left sided pressures with a 20 mmHg gradient across the aortic
valve and
a normal cardiac index (3.4 l/min/m2).
6. Left ventriculography showed no wall motion abnormalities
(EF 60
to 65%) with no mitral regurgitation.
6. Successful stenting of the right CIA with a 7.0 mm Genesis
stent.
7. Successful stenting of the left subclavian artery with a
6.0 mm
Genesis stent, post-dilated to 7.0 mm.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent SVG to RCA, occluded SVG to OM, patent SVG to D1 to
D2.
3. Patent LIMA to LAD.
4. Moderate Aortic Stenosis.
2. Successful stenting of the right CIA.
3. Successful stenting of the left subclavian artery.
CT BRAIN [**4-15**]:
NON-CONTRAST HEAD CT SCAN: There are multiple large rounded
lesions within the brain which are hyperdense, consistent with
hemorrhagic metastases. At least six metastatic lesions are
visualized. There is a large hemorrhagic lesion involving the
right occipital lobe measuring 4.3 cm in diameter. A larger more
ill-defined lesion is noted within the right parietal lobe
superiorly. Other lesions are found within bilateral frontal
lobes. There is a moderate amount of edema surrounding the
hemorrhagic metastasis, demonstrated as hypodensity of the
surrounding white matter. There is no shift of the normally
midline structures at this time. The large right occipital
hemorrhagic metastasis results in mass effect on the occipital
[**Doctor Last Name 534**] of the right lateral ventricle. The third and fourth
ventricles are unremarkable. The visualized paranasal sinuses
and mastoid air cells are clear. Osseous and soft tissue
structures are unremarkable.
IMPRESSION: Multiple hemorrhagic metastases within the brain.
MRI WITH CONTRAST [**4-17**]:
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with history of cancer with
cardiac catheterization and intracranial hemorrhage for further
evaluation to rule out metastatic disease.
TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion axial images of the brain were obtained before
gadolinium. T1 sagittal, axial and coronal images were obtained
following gadolinium. Correlation was made with the head CT of
the same date, [**2145-4-16**].
FINDINGS: There are multiple areas of signal abnormalities seen
within the both cerebral hemispheres. The largest lesion now
measuring 5 x 3 cm demonstrating acute blood products is seen in
the right occipital region with surrounding edema. There is
irregular rim enhancement seen following the administration of
gadolinium which extends to subependymal enhancement of the
occipital [**Doctor Last Name 534**] of the right lateral ventricle. The occipital
[**Doctor Last Name 534**] of the right lateral ventricle is compressed. Additionally,
several rounded areas of enhancement and signal changes are seen
in both cerebral hemispheres measuring 1-2 cm in size involving
the frontal and parietal lobes consistent with mild surrounding
edema. These findings are consistent with metastatic disease.
There is mild mass effect on the right lateral ventricle without
significant midline shift. The basal cisterns are patent. There
is mild brain atrophy identified.
IMPRESSION: Findings indicative of hemorrhagic metastatic
disease with the largest lesion in the right occipital lobe and
several other lesions measuring from 1-2 cm in both frontal and
parietal lobes. Mass effect is seen on the right lateral
ventricle without midline shift.
[**4-17**] CXR:
Single portable chest radiograph demonstrates interval
development of moderate, bilateral, pleural effusions when
compared to [**2145-4-17**]. Additionally, there is interval
development of prominence of the pulmonary vasculature,
representing worsening CHF. Trachea is in the midline. A right
subclavian central venous catheter remains unchanged in
position. Surgical clips project over the mediastinum. The
patient is again seen to be status post median sternotomy.
IMPRESSION:
Worsening CHF.
[**4-19**] CXR:
Findings; compared to [**2145-4-18**], there is a new Dobbhoff tube with
the tip projecting over the mid abdomen. Right subclavian CVL is
unchanged. Pulmonary edema has worsened. There is a new left
perihilar consolidation. There are small bilateral pleural
effusions. Left subclavian stent reidentified.
IMPRESSION:
1. Interval worsening of pulmonary edema with bilateral pleural
effusions.
2. New left perihilar consolidation.
Brief Hospital Course:
82 yo woman with cad, pvd, htn, high chol, breast ca in the
past, and questionable history of colon cancer 2 yrs ago, who
developed left sided weakness morning after cath, as well as L
extinction on DSS, L homonomous hemianopsia, and at least two
periods of unresponsiveness lasting at least several minutes in
duration suggestive of seizures, with CT scan showing multiple
areas of hemorrhage in both cerebral hemispheres, and large left
occipito-parietal hemorrhage suggestive of bleeding into mets
(vs amyloid, less likely). No hypertension to suggest that this
was HTN related. She was dilantin loaded and started on
standing dilantin. The head of the bed was kept above 30
degrees, and MRI was ordered.
The patient had initially been admitted to the vascular surgery
service with cardiology consulting for the catheterization. She
was transferred to the neuro ICU for additional care. Code
status was discussed with the patient and with her family, and
she expressed wishes that she did not want to be on a
ventillator to prolong her life. She was also informed of the
likelihood (based on head CT) that the brain lesions were
metastases and that her prognosis was poor. MRI of the brain
with gado confirmed that these lesions were likely mets.
CT of the torso for further metastatic workup was desired, but
the patient developed acute renal failure thought related to
contrast nephropathy. She was given IV fluid, which exacerbated
her already poor cardiac function, and she developed CHF. She
was maintained on BiPAP (NIPPV) in the ICU for several days; the
family again mentioned that she should under no circumnstances
be intubated. On [**4-19**], her creatinine had improved, and she was
weaned from BiPAP to facemask with 10L O2. She had also had an
elevated WBC count and some chest xray evidence of pneumonia at
this time. Because she had clinically improved, a feeding tube
(Dobhoff) was placed and she was transferred to the stepdown
unit for further management. At this point she was following
commands, answering simple questions (limited by her shortness
of breath), lifting the left arm against gravity with some
resistance as well, right arm remained full strength, and she
still had the left homonomous hemianopsia, although extraocular
muscles were intact in their movements.
Within hours of transfer to the floor, she developed respiratory
distress and as BiPAP could not be arranged on the floor at that
time, she was transferred back to the ICU (SICU now).
Clinically, her neuro exam remained stable and her kidney
function improved; she diuresed well. However, she was still
requiring facemask. Neuro-oncology was curbsided regarding
?palliative measures, and neuro-onc agreed that given her story
she was likely a poor candidate for chemo. The numerous brain
lesions could be treated with whole brain irradiation as one
palliative measure. Radiation oncology was consulted and agreed
that this was a possibility if the family desired it. On [**4-21**]
she dropped her sats again and developed further respiratory
distress while in the ICU. As her clinical status had not
adequately improved within days, and because the underlying
process was thought to be irreversible, another family
discussion was held and she was made CMO. She was given
morphine for air hunger and for comfort, and other medications
aimed at treating underlying processes were discontinued. She
expired on [**4-24**] at 5:45 am. Immediate cause of death was
respiratory failure. The family declined an autopsy.
Medications on Admission:
Hm meds include metoprolol, lisonpril, norvasc, asa 81, lipitor
80, HCTZ; Plavix added in house post stent. Last heparin gtt at
1200 on [**4-15**]
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Cerebral hemorrhages
Discharge Condition:
Deceased
Discharge Instructions:
none
Followup Instructions:
none
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
|
[
"4241",
"5849",
"4280",
"486",
"41401",
"4019",
"2720",
"25000",
"V4581"
] |
Admission Date: [**2201-6-3**] Discharge Date: [**2201-6-17**]
Date of Birth: [**2123-5-25**] Sex: M
Service: SURGERY
Allergies:
Hydralazine
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Upper Endoscopy [**2201-6-4**]
Exploratory Laparotomy, Anterior Nissen fundoplication repair of
Paraesophageal hernia [**2201-6-6**]
History of Present Illness:
This is a 78 year old male who presents with repeated episodes
of coffee ground emesis. He says he initially had a dry cough of
one week in duration and then awoke early this morning with a
coughing fit followed by transient epigastric pain and nausea.
He then had several episodes of brown emesis and decided to be
evaluted in the ER. On presentation to the ER he says his pain
has mostly resolved. He did not see frank blood and had no
hematochzia or melena. He has no anorexia and is not taking
NSAIDS or aspirin; he did not recently drink alcohol. He denies
fever or chills. He has no conspitation or diarrhea.
Past Medical History:
Atrial Fibrillation
[**Hospital3 9642**] Mitral Valve repair in '[**89**] for regurgitation
Cholilithiasis
Hyperlipidemia
Homocystinemia
Basal cell carcinoma
Hemorrhoidectomy
Hypertension
Cataracts
Social History:
The patient lives alone . He has a history of smoking but quit
40 years ago. He drinks 1 glass of alcohol a day.
Family History:
There is a history of colon cancer
Physical Exam:
On admission:
v/s 98.8, 127/89, 84, 25, 98 room air
Gen: WD/WN elderly male in no acute distress, alert and awake
HEENT: NC/AT, anicteric, EOMI, PERRL
CV: irregular irregular with mechanical valve click
auscultatable
Pulm: clear to auscultation bilaterally
Abd: + normoactive bowel sounds, soft, mild distension, no
tenderness, no rebound, no CVAT
Extr: warm, 2+ DP bilaterally, well-perfused
Rectal: no stool in vault, guaic negative
Pertinent Results:
SEROLOGIES:
[**2201-6-3**] 06:00PM BLOOD WBC-10.3# RBC-4.74 Hgb-16.0 Hct-45.5
MCV-96 MCH-33.7* MCHC-35.1* RDW-12.9 Plt Ct-150
[**2201-6-4**] 06:00AM BLOOD WBC-8.9 RBC-4.24* Hgb-13.9* Hct-40.7
MCV-96 MCH-32.8* MCHC-34.1 RDW-12.7 Plt Ct-120*
[**2201-6-5**] 04:44AM BLOOD WBC-9.0 RBC-4.12* Hgb-13.8* Hct-39.8*
MCV-97 MCH-33.4* MCHC-34.5 RDW-12.7 Plt Ct-118*
[**2201-6-6**] 03:43AM BLOOD WBC-6.6 RBC-3.38* Hgb-10.8*# Hct-31.8*
MCV-94 MCH-31.9 MCHC-33.9 RDW-14.4 Plt Ct-122*
[**2201-6-7**] 05:40AM BLOOD WBC-7.0 RBC-3.62* Hgb-11.7* Hct-34.7*
MCV-96 MCH-32.3* MCHC-33.7 RDW-14.0 Plt Ct-121*
[**2201-6-8**] 06:28AM BLOOD WBC-9.2 RBC-3.86* Hgb-12.3* Hct-37.3*
MCV-97 MCH-31.9 MCHC-33.0 RDW-13.6 Plt Ct-130*
[**2201-6-13**] 05:50AM BLOOD WBC-7.7 RBC-3.62* Hgb-11.6* Hct-34.6*
MCV-95 MCH-32.0 MCHC-33.5 RDW-13.4 Plt Ct-187
[**2201-6-15**] 06:40AM BLOOD WBC-9.2 RBC-3.59* Hgb-11.3* Hct-34.5*
MCV-96 MCH-31.6 MCHC-32.9 RDW-13.2 Plt Ct-261
[**2201-6-3**] 06:00PM BLOOD PT-19.3* PTT-30.0 INR(PT)-2.5
[**2201-6-4**] 12:30AM BLOOD PT-20.5* PTT-31.6 INR(PT)-2.8
[**2201-6-6**] 03:43AM BLOOD PT-14.1* PTT-28.9 INR(PT)-1.3
[**2201-6-15**] 06:40AM BLOOD PT-16.9* PTT-66.8* INR(PT)-1.9
[**2201-6-16**] 06:58AM BLOOD PT-17.7* PTT-70.4* INR(PT)-2.1
[**2201-6-17**] 06:35AM BLOOD PT-19.0* PTT-68.5* INR(PT)-2.4
[**2201-6-3**] 06:00PM BLOOD Glucose-131* UreaN-21* Creat-1.3* Na-143
K-4.8 Cl-106 HCO3-22 AnGap-20
[**2201-6-4**] 06:00AM BLOOD Glucose-129* UreaN-18 Creat-1.2 Na-146*
K-3.8 Cl-110* HCO3-26 AnGap-14
[**2201-6-5**] 04:44AM BLOOD Glucose-115* UreaN-17 Creat-1.3* Na-144
K-3.8 Cl-110* HCO3-25 AnGap-13
[**2201-6-9**] 05:50AM BLOOD Glucose-118* UreaN-27* Creat-1.3* Na-146*
K-4.7 Cl-108 HCO3-27 AnGap-16
[**2201-6-10**] 07:24AM BLOOD Glucose-135* UreaN-27* Creat-1.1 Na-148*
K-3.7 Cl-109* HCO3-30* AnGap-13
[**2201-6-12**] 08:30AM BLOOD Glucose-101 UreaN-17 Creat-1.1 Na-143
K-2.9* Cl-107 HCO3-26 AnGap-13
[**2201-6-13**] 05:20PM BLOOD Glucose-124* UreaN-16 Creat-1.3* Na-136
K-4.7 Cl-102 HCO3-26 AnGap-13
[**2201-6-14**] 05:55AM BLOOD Glucose-105 UreaN-14 Creat-1.2 Na-139
K-4.0 Cl-105 HCO3-26 AnGap-12
[**2201-6-15**] 06:40AM BLOOD Glucose-110* UreaN-13 Creat-1.1 Na-140
K-4.6 Cl-108 HCO3-21* AnGap-16
[**2201-6-3**] 06:00PM BLOOD Albumin-4.4
[**2201-6-12**] 08:30AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.8
[**2201-6-14**] 05:55AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.3 Cholest-132
[**2201-6-15**] 06:40AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.1
[**2201-6-14**] 05:55AM BLOOD Triglyc-115 HDL-32 CHOL/HD-4.1 LDLcalc-77
[**2201-6-6**] 12:34AM BLOOD Glucose-120* Lactate-2.3* Na-148 K-3.7
Cl-107
[**2201-6-6**] 02:23AM BLOOD Glucose-152* Lactate-1.7 Na-147 K-3.1*
Cl-108
[**2201-6-6**] 06:48PM BLOOD Lactate-1.5
[**2201-6-7**] 05:46AM BLOOD Lactate-1.4
RADIOLOGY:
[**2201-6-5**] Upper GI study: 1) Short-segment narrowing of the distal
esophagus. The differential diagnosis includes a peptic
esophageal stricture. A neoplastic lesion cannot be excluded.
2) Large type 3 hiatal hernia with a large paraesophageal
component and
elevation of the gastroesophageal junction above the level of
the
diaphragmatic hiatus.
3) Nonpassage of contrast into the duodenum with a poorly
evaluated pylorus. Several images demonstrate a swirling pattern
of the gastric mucosa that raises the question of gastric
torsion. There is residual barium material present within the
esophagus at the termination of this exam. Suction via an NG
tube may be considered. Delayed images may also be considered.
[**2201-6-11**] CXR: 1) Increasing bilateral pleural effusions (left
greater than right); left lower lobe consolidation/atelectasis.
2) Interval improvement in CHF/volume overload.
PATHOLOGY:
[**2201-6-6**] Esophageal hernia sac:
Fragments of fibromuscular and adipose connective tissue with
vascular congestion; unremarkable skeletal muscle.
GASTROENTEROLOGY:
[**2201-6-4**] EGD: Friability and erythema in the middle third of the
esophagus and lower third of the esophagus. Edema and narrowing
if the distal esophagus and GE junction. These changes could be
secondary to severe GERD or may represent a neoplasm. Deformity
of the pylorus.
Otherwise normal egd to stomach body
Brief Hospital Course:
This is a 78 year old gentleman on anticoagulation for a mitral
valve who presented with several bouts of brown emesis on
[**2201-6-3**]. On presentation in the ER the patient was noted to be
hemodynamically stable with a stable hematocrit at 40 but having
repeated episodes of emesis with NGT lavage revealed some bright
red blood. He had an endoscopy performed on hospital day 2 which
revealed friability and erythema at the distal third of the
esophagus with differential including esophagitis or neoplasm.
He was started on carafate and protonix. A barium swallow was
conducted which demonstrated a paraesophageal hernia with
possible volvulus. Surgery was consulted on hospital day 2 and
the patient was taken to the operating room on [**2201-6-6**] for
repair of his paraesophageal hernia via an open anterior Nissen
approach (please see the operative note of Dr. [**Last Name (STitle) **] for
full details). This operation went well without complications.
He was extubated uneventfully on post-operative day 1 and
started on a heparin drip for his mitral valve. Neurologically
he did well with dilaudid IV for pain control which was
transitioned to oral dilaudid. His atrial fibrillation was well
rate-controlled with beta-blockade. He was started on clears on
post-operative day 3 which he tolerated well; protonix was used
for GI prophylaxis. His diet was advanced to a regular diet by
post-operative day 5 and he had a bowel movement. He was started
on Coumadin with the therapeutic level attained by day of
discharge and his primary care physician was notified regarding
monitoring of his INR levels. He worked with physical therapy
and was found to be safe for home with a visiting nurse by time
of discharge. His staples were removed on post-operative day 10.
He was discharged to home on post-operative day 11 with planned
follow-up in [**1-11**] weeks. All questions were answered to his
satisfaction upon discharge.
Medications on Admission:
Coumadin 5 mg oral qdaily
Vitamin B6
Vitamin B 12
Folate
Zocor 10 mg oral qdaily
Atenolol 50 mg oral qdaily
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
4. Hydromorphone HCl 2 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Warfarin Sodium 6 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): ( total of 7 mg every night unless prescription
changes).
Disp:*30 Tablet(s)* Refills:*2*
6. Coumadin 1 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Pyridoxine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Outpatient Lab Work
INR check on [**2201-6-18**] (goal level 2.5 to 3.5)
10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet,
Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary: Strangulated Paraesophageal Hernia
Secondary: Hypertension, history of atrial fibrillation, history
of a mechanical mitral valve, history of cholelithiasis
Discharge Condition:
Good
Discharge Instructions:
Take all medications as prescribed. You may eat a regular diet
and resume your regular activity, but no lifting of heavy
objects fo up to one month. You should return to the ER or call
the office with any worsening abdominal pain, nausea, fever to
101, or drainage/bleeding from your wound. Please call with
questions.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**]
CARDIAC SERVICES Phone:[**Telephone/Fax (1) 10464**] Date/Time:[**2201-12-17**] 9:00
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 55809**] Call to schedule
appointment
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 2981**] Call to schedule
appointment within 1-2 weeks
You should follow-up with Dr. [**First Name4 (NamePattern1) 4559**] [**Last Name (NamePattern1) 104147**], your primary
care physician, [**Name10 (NameIs) **] this week. He has been notified of your
hospital stay and would like to see you on Friday 6/10/5.
Completed by:[**2201-6-17**]
|
[
"42731",
"2724",
"4019"
] |
Admission Date: [**2192-7-11**] Discharge Date: [**2192-7-26**]
Date of Birth: [**2192-7-11**] Sex: F
Service: NB
HISTORY OF PRESENT ILLNESS: Baby girl [**Known lastname **] is a newborn
2320-gram 32 [**5-12**] week premature infant admitted to the NICU
with prematurity.
She was born on [**2192-7-11**] at 1:43 p.m. to a 34-year-old
G4/P3 (now 4) mother with an [**Name (NI) 37516**] of [**2192-8-31**]. Prenatal
labs include blood type O positive, antibody negative,
hepatitis B surface antigen negative, RPR nonreactive,
rubella immune, GBS positive. Pregnancy notable for normal
fetal survey, normal triple screen. Pregnancy complicated by
question of PPROM at 27 weeks, with admission at that time
for early preterm labor. She was treated with antibiotics,
magnesium, and betamethasone; with betamethasone course
complete on [**6-3**]. Labor subsided. Mother was readmitted on
[**7-2**] at 31+ weeks with contractions not requiring
tocolytic therapy. She presented again with preterm
contractions on day of delivery and progressed to labor and
eventual delivery.
Perinatal period notable for treatment with penicillin
prophylaxis beginning 8 hours prior to delivery and maternal
temperature of 99.8.
At delivery the infant emerged vigorous with Apgars of 9 and
9. Mildly increased work of breathing was noted. She was
brought to the NICU for further management.
PHYSICAL EXAMINATION ON ADMISSION: Weight of 2320 grams
(90th percentile), length of 45 cm (75th percentile), head
circumference of 29.75 cm (25th to 50th percentile). Vital
signs: T 98.9, HR 160, RR 50 to 60, BP 67/37, O2 saturation
99% on room air. A well- developed premature infant, active,
vigorous, mild tachypnea at rest, responsive to exam,
fontanel soft and flat, mild molding, positive red reflex
bilaterally. Ears and nares patent. Palate intact. Lungs with
moderate aeration, clear, minimal retractions. Cardiac exam
reveals a regular rate and rhythm. No murmur. Abdomen is
soft. No HSM. No mass. 3-vessel cord. GU reveals normal
female. Patent anus. Femoral pulses 2+. Extremities reveal
hips/back normal. No edema. Neuro reveals grossly normal tone
and activity. Intact grasp, weak suck.
LABORATORY DATA ON ADMISSION: Dextrostix of 53.
HOSPITAL COURSE BY SYSTEMS: Dictation is being done on day
of life #16. The following is a summary of the hospital
course by systems.
1. RESPIRATORY: The patient has been in room air during
entire hospital course.
2. CARDIOVASCULAR: No active issues during hospitalization.
3. FEN: The patient was n.p.o. until day of life 2, at which
time she was slowly advanced on PG/PO feeds to full PO
feeds. Her weight at discharge is 2620g. She is currently
on breast milk 24 calories per ounce, Fe 0.25 cc p.o.
daily, and Vi-Daylin 1 cc p.o. daily.
4. GI: No phototherapy during hospitalization. No active
issues. However, the baby has an excoriated perianal
region and diaper dermatitis with candidal dermatitis.
Currently being treated with Desitin and Nystatin topical
creams.
5. HEMATOLOGY: Initial hematocrit of 40.4. No transfusions
during hospitalization.
6. ID: Initial white blood count of 13.8, 32 segs, 7 bands,
54 lymphocytes. Ampicillin and gentamicin continued until
day of life 2 when blood cultures negative x 48 hours.
7. NEUROLOGY: No head ultrasound performed secondary to
advanced gestational age.
8. OPHTHALMOLOGY: No eye exam performed secondary to advanced
gestational age.
9. SENSORY/AUDIOLOGY: Hearing screen performed with
automated auditory brain stem responses; Passed both ears.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: To home.
NAME OF PRIMARY PEDIATRICIAN: [**Location (un) 669**] Comprehensive Community
Health Center, Dr [**Last Name (STitle) 51036**]; [**Telephone/Fax (1) 63367**].
CARE AND RECOMMENDATIONS:
1. Feeds at discharge: To continue on breast milk at 24
calories per ounce formula.
2. Medications: Ferrous sulfate 0.25 cc p.o. daily, Vi-Daylin
1 cc p.o. daily.
3. Car seat position screening: Passed
IMMUNIZATIONS RECEIVED: Hepatitis B #1 on [**2192-7-23**].
IMMUNIZATIONS RECOMMENDED:
1. Synagis RSV prophylaxis should be considered from [**Month (only) **]
through [**Month (only) 958**] for infants who meet the following 3 criteria:
(1) born at less than 32 weeks; (2) born between 32 and 35
weeks with 2 of the following: Daycare during RSV season, a
smoker in the household, neuromuscular disease, airway
abnormalities, or school-age siblings; or (3) with chronic
lung disease.
2. Influenza immunization is recommended annually in the Fall
for all infants once they reach 6 months of age. Before this
age (and for the first 24 months of the child's life)
immunization against influenza is recommended for household
contacts and out of home caregivers.
DISCHARGE FOLLOWUP: Follow-up appointment will be made
within 2 to 3 days of discharge.
DISCHARGE DIAGNOSES:
1. Prematurity
2. Rule out sepsis
3. Monilial diaper rash
[**Name6 (MD) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55472**]
Dictated By:[**Last Name (NamePattern1) 60761**]
MEDQUIST36
D: [**2192-7-26**] 15:15:28
T: [**2192-7-26**] 15:49:28
Job#: [**Job Number 63368**]
|
[
"V290",
"V053"
] |
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